Elusive left ventricular thrombus: Diagnostic role of cardiac magnetic resonance imaging-A case report and review of the literature.

Identification of left ventricular mural thrombus (LVT) may be challenging depending on the imaging modality used. We present a case of LVT which was incidentally identified on cine cardiac magnetic resonance imaging (CMR). A sixty-four years old female presented with worsening dyspnea on exertion with troponin elevation. Transthoracic echocardiography (TTE) revealed a dilated left ventricle (LV) and ejection fraction (EF 30%) with thinning and akinesis of inferior/inferolateral wall was noted with basal and mid inferior wall aneurysm, and thrombus was not identified. CMR done to ascertain viability of myocardium revealed a mural thrombus within basal inferior aneurysm. This was not visualized on transthoracic echocardiography with and without use of contrast. She underwent coronary artery bypass grafting, bioprosthetic mitral valve replacement, resection and plication of posterior left ventricular aneurysm with removal of mural thrombus, and was started on anticoagulation with warfarin post-operatively for the apical thrombi. Cardiac magnetic resonance is a well suited imaging modality in detecting LVT due to its high resolution images and is more reproducible than TTE. In our patient, conventional TTE despite administration of echo-contrast agents failed to diagnose the presence of LVT in the basal inferior aneurysm as well as the apical thrombi. Delayed-enhancement CMR provides the greatest sensitivity for detection of left ventricular thrombus, superior to standard transthoracic and contrast-enhanced transthoracic echocardiography.

Webbed left atrial septal pouch-A new anatomical variant.

Atrial septal pouch is a recently described anatomical entity. We describe webbed left atrial septal pouch (LSP), a new variant in the spectrum of fusion of septum primum and septum secundum. In the continuum of the natural history of atrial septal closure from patent foramen ovale (PFO) to complete fusion of the septum, we propose the septal anatomy in our patient to be secondary to partially developed adhesions or septa. Potential association of LSP with stroke due to in situ thrombosis and atrial fibrillation has been described. Recognition of septal anatomy is vital to avoid complications related to transseptal puncture.

Incidental echocardiographic finding: Fractured inferior vena cava filter.

Inferior vena cava filters have gained increasing popularity in recent decades and knowledge on rare complications becomes vital to practicing physicians. A 30-year-old African American male with diabetes mellitus, hypertension, end-stage renal disease, history of deep venous thrombosis and placement of venacaval filter who was seen in the cardiology clinic for cardiac risks stratification prior to renal transplant. Patient denied any cardiac symptoms. A transthoracic echocardiogram was performed and showed two linear echoes bright densities in the right atrium and right ventricle embedded which was later found to be fractured filter struts by computed tomography. We discuss the various outcomes associated with non-retrieval of retrievable inferior vena cava filters.

Clinical significance of a presystolic wave on Doppler examination of the left ventricular outflow tract.

A presystolic wave (PSW) is commonly seen on Doppler examination of the left ventricular outflow tract (LVOT), but is little studied. We conducted a retrospective study to assess the prevalence of the PSW, correlations with various Doppler parameters, and its clinical significance. Two hundred echocardiograms, 100 with ejection fraction (EF) >55% and 100 with EF <45%, were reviewed. Mitral inflow velocities, septal annular velocities, LVOT, and PSW velocities were measured. Major adverse cardiovascular events (MACE [death, heart failure hospitalization, atrial fibrillation, and stroke]) were compared between those with and without a PSW, in both EF groups. Mean age was 58 ± 15 years; 56% were men and 69% were African-American. PSW prevalence was similar between normal (68%) and reduced EF groups (62%). However, its velocity was less in the low EF group (37 ± 10 vs 48 ± 16 cm/s, p <0.0001). In subjects with normal EF PSW velocity correlated with mitral A velocity (rho = 0.43, p = 0.0003). In subjects with reduced EF the association with A velocity was not significant (rho = 0.22, p = 0.09), but there was a significant association with annular a' velocity (rho = 0.38, p = 0.002). Over a mean follow-up of 1.7 ± 0.3 years, 57 subjects (28%) experienced MACE. Those without a PSW had more MACE (39% vs 23%, p = 0.02); PSW absence remained predictive of MACE after adjustment for multiple variables, especially in patients with reduced EF. In conclusion, PSW is common in the LVOT. Its presence and magnitude are associated with measures of atrial contraction. Its absence is associated with increased rates of adverse events, especially in patients with low EF.

Accuracy of transthoracic echocardiography for the measurement of the ascending aorta: comparison with transesophageal echocardiography.

BACKGROUND: There has been a substantial increase in the number of imaging studies performed to assess thoracic aortic pathology. We sought to determine the accuracy of transthoracic echocardiography (TTE) compared to transesophageal echocardiography (TEE) for measuring ascending aortic size. HYPOTHESIS: Transthoracic echocardiography is reasonably accurate for assessing ascending aortic dimension. METHODS: Fifty-two patients with or without aortic disease underwent both TTE with nonstandard views and TEE. The ascending aorta was measured at 4 levels by 2 blinded observers for each modality. Pearson's correlation coefficients were determined and Bland-Altman plots and analyses were constructed. Inter- and intraobserver variability was determined in a random subgroup of patients. RESULTS: The mean age of the group was 65.5 years old and 15% had aortic dilation >4.0 cm. A strong positive correlation between the 2 imaging modalities was seen at all levels with the highest correlation for the maximum diameter of the ascending aorta (r = 0.936, P < 0.0001). Interobserver and intraobserver variability showed a good intraclass correlation among readers and among the same reader at all levels. CONCLUSIONS: Transthoracic echocardiography using nonstandard imaging windows is accurate in comparison to TEE for measurement of the ascending aorta at multiple levels in patients with or without aortic pathology. The findings of this study provide support for selected serial follow-up of patients with aortic disease by TTE only.

Reclassification of patients for aggressive cholesterol treatment: additive value of multislice coronary angiography to the National Cholesterol Education Program guidelines.

BACKGROUND: National Cholesterol Education Program (NCEP) guidelines have been used to define treatment goals in patients with hypercholesterolemia. However, epidemiology-based guidelines are unable to identify all subjects with coronary artery disease for aggressive lipid intervention. OBJECTIVE: We sought to evaluate the additive value of multislice computed tomography (MSCT) angiography to the NCEP guideline classification for lipid treatment. METHODS: Multislice computed tomography was performed in 114 consecutive patients (mean age 57+/-14 y; 59% male) without known coronary artery disease. Subjects were classified into 3 categories (low-, intermediate-, and high-risk) according to their Framingham risk scores (FRS). RESULTS: Traditional cardiac risk factors were common: hypertension 59%, diabetes 13%, and smoking 22%. On the basis of the FRS, 11% (n=12/114) of the patients met high-risk criteria requiring aggressive cholesterol reduction. Of those in the low- and intermediate-risk groups, MSCT found coronary plaque in 76% (n=77/102), with moderate or severe plaque in 38% (n=39/102), thus reclassifying them in the high-risk category. Use of statin drugs increased from 32% at baseline to 53% (p=0.002) based on MSCT results; statin dose was increased in 31% of the patients who were already on a statin. The mean low-density lipoprotein cholesterol (LDL-c) decreased from 114 mg/dL to 91 mg/dL after MSCT (p<0.001). CONCLUSION: Multislice computed tomography reclassifies a high percentage of patients considered to be low- to intermediate-risk into the high-risk category based on their coronary artery lesions. Thus, the rise in MSCT use at present may have a large impact on clinician practice patterns in lipid-lowering therapy.