Im Board Review

Left ventricular thrombosis can still complicate acute myocardial infarction

Muhammad Umer Tariq, MD, Ali M. Tariq, MD, Carmela D. Tan, MD, E. Rene Rodriguez, MD and Venu Menon, MD
Cleveland Clinic Journal of Medicine November 2016, 83 (11) 819-826; DOI: https://doi.org/10.3949/ccjm.83a.14078

Article Figures & Data

Figures

  • FIGURE 1
    FIGURE 1

    Transthoracic echocardiography, apical four-chamber view, shows thrombus in the left ventricular apical cavity. The blue arrow points to the well-demarcated thrombus adhering to the endocardium.

  • FIGURE 2
    FIGURE 2

    (A) A cross section of the apical segment of the left ventricle shows a mildly dilated cavity filled with mural thrombus. (B) Photomicrograph of an acute thrombus shows alternating layers of fibrin and platelet with red and white blood cells (hematoxylin and eosin, original magnification × 200). (C) Organization of a thrombus is characterized by infiltration of fibroblasts and newly formed capillaries (hematoxylin and eosin, original magnification × 200).

  • FIGURE 3
    FIGURE 3

    Cardiac magnetic resonance imaging with a delayed-enhancement phase-sensitive inversion recovery image, vertical long-axis view. The red arrow points to dense subendocardial delayed enhancement in the apex extending into the mid-inferior wall, consistent with scar in the distal left anterior descending artery territory. The orange arrow shows a nonenhancing mass in the apex, consistent with thrombus.

Tables

  • TABLE 1

    Incidence of left ventricular thrombosis after ST-segment elevation myocardial infarction

    AuthorsNo. of patientsaIncidence of left ventricular thrombosisPredictors of left ventricular thrombosis
    Kalra and Jang,4
    2000    		    71  4%Anterior infarction
    Nayak et al,5
    2004    		  20011%Anterior infarction
    Rehan et al,6
    2006    		    92  4%Anterior infarction
    Zielinska et al,7
    2008    		2,911  2.5%Anterior infarction
    Left ventricular ejection fraction < 40%
    Hypertension
    Osherov et al,8
    2009    		  642  6%Severe mitral valve regurgitation
    Low left ventricular ejection fraction
    Solheim et al,9
    2010    		  10015%Higher peak creatine kinase level
    Larger infarcts
    Lower left ventricular ejection fraction
    Shacham et al,10
    2013    		  207  5%Higher C-reactive protein levels
    Higher fibrinogen levels
    Gianstefani et al,11
    2014    		1,059  4%Low left ventricular ejection fraction
    Anterior infarction
    Use of glycoprotein IIb/IIIa inhibitors

    • ↵a Most patients underwent percutaneous coronary intervention.

  • TABLE 2

    Bleeding risk after percutaneous coronary intervention: Triple thrombotic therapy vs dual antiplatelet therapy

    AuthorsNo. of patientsAbsolute difference in major bleeding with warfarinComments
    Khurram et al,49 20061076.6% higherBleeding defined as requiring > 2 units of packed red blood cells, or intraocular or disabling bleeding
    DeEugenio et al,52 200719411% higherHazard ratio 5.0 (95% confidence interval [CI] 1.4–17.8) with warfarin
    Karjalainen et al,40 20074785.6% higherOdds ratio 3.4 (95% CI 1.2–9.3) with warfarin
    Increased stent thrombosis with warfarin-aspirin combination
    Ruiz-Nodar et al,53 20084265.9% higherAll patients had atrial fibrillation
    Mortality rate was higher without anticoagulation
    Sarafoff et al,54 20085151.7% lower (not statistically significant)Both dual antiplatelet therapy and triple therapy had favorable efficacy and safety
    Rossini et al,55 2008b2040.9% higher (not statistically significant)Bleeding rate was lower if the international normalized ratio was kept between 2 and 2.5: 4.9% vs 33% at 3 months

    • ↵a This was a prospective study. The other studies in this table were retrospective.

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