JACC: CARDIOVASCULAR IMAGING
VOL. 4, NO. 7, 2011
© 2011 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-878X/$36.00
PUBLISHED BY ELSEVIER INC.
DOI:10.1016/j.jcmg.2011.05.002
EDITORIAL COMMENT
Detecting LV Thrombi
“T’ain’t What You Do (It’s the Way That You Do It)”*†
Richard W. Asinger, MD, Charles A. Herzog, MD
Minneapolis, Minnesota
Detection of intracardiac masses has long been recognized as a strength of transthoracic 2-dimensional
echocardiography (TTE) (1). The sensitivity and
specificity of TTE for detection of left ventricular
thrombus (LVT) was established by comparison of
“adequate” TTEs on highly select patients with surgical or post-mortem findings (2– 4). It quickly became
and remains the preferred method to detect LVT.
See page 702
In this issue of iJACC, Weinsaft et al. (5), report
performance characteristics of clinical TTE for
detection of LVT in a consecutive series of patients
with left ventricular dysfunction from a dedicated
cardiac magnetic resonance (CMR) registry. A
research protocol delayed-enhancement CMR
(DE-CMR), shown to have high sensitivity and
specificity for detecting LVT (6), was performed to
evaluate for LVT and compared with a “clinical
TTE” performed within 1 week of registry DECMR. For this and another study comparing CMR
and TTE for detecting LVT (7), all CMR patients
were included regardless of TTE quality although
the selection criteria were not clearly described. The
prevalence of LVT in the article by Weinsaft et al.
(5) DE-CMR was 10% and TTE 12% but there
was substantial “discordance” between the 2 techniques. Clinical/pathology endpoints at 6-month
follow-up were higher in patients with LVT de-
*Editorials published in JACC: Cardiovascular Imaging reflect the views of
the authors and do not necessarily represent the views of JACC: Cardiovascular Imaging or the American College of Cardiology.
From the Cardiology Division, Department of Internal Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis, Minnesota. †Oliver MS, Young JT. T’aint What You Do (It’s the
Way That You Do It). Available at: http://www.youtube.com/watch?v⫽
X8fCXNTCWig#t⫽1m08s. Accessed April 14, 2011. The authors have
reported that they have no relationships to disclose.
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tected by DE-CMR, which the investigators feel
“support DE-CMR as an appropriate reference
standard.” The sensitivity, specificity, and predictive
value of clinical TTE for detection of LVT compared with the DE-CMR reference standard are
reported noting that use of an echocardiographic
contrast agent, a method reported to increase the
predictive value of TTE for LVT detection (8 –10)
was infrequent. As the investigators stress, this
should not be considered a direct comparison of the
2 methods. An “intent to image” comparison of the
2 imaging modalities in a general population where
those with “inadequate” TTEs and “contraindicated” DE-CMR were excluded may show different
results. The predictive value of TTE was higher
when the clinical indication was to evaluate for LVT
and the quality of the TTE high. Smaller “intracavitary” and mural LVT, regardless of size, were more
commonly detected by DE-CMR than by clinical
TTE. The investigators conclude that routine clinical
echo can yield misleading results concerning detection
of LVT (5).
The dismal performance of routine TTE in
contrast to DE-CMR raises concern regarding the
reliability of TTE for detecting LVT. Original
reports of the reliability of TTE for detecting LVT
were from adequate TTE studies of high-risk patients, focused on detecting LVT (2– 4). Inadequate
or inconclusive TTEs have been reported in a high
percentage of patients being evaluated for LVT
(9,11) when echo contrast was not used. In part,
this may explain the poor performance of TTE in
the investigators’ report. Nevertheless, the observations point out potential limitations of routine
clinical TTE for detecting LVT, particularly when
the indication is not specific and echo contrast is
used infrequently. These results send clear messages
to clinicians and echocardiographers.
714
Asinger and Herzog
Editorial Comment
JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 7, 2011
JULY 2011:713–5
First is the importance of the specific indication for
TTE. If LVT was the indication, TTE’s sensitivity for
detecting LVT nearly doubled in the study by Weinsaft et al. (5). If the indication is vague, TTE becomes
a “screening” tool and its performance is reduced. The
second relates to the technical performance of TTE.
Useful techniques for detection of LVT and avoidance
of false positives by TTE include attention to the LV
apex (the most common site for LVT) where multiple
depths of field, high transducer frequency, nonstandard acoustic windows, varying gain and sensitivity
settings and verification on more than view are important (3,12). Previous and serial TTEs can also be
valuable in understanding the anatomy of the left
ventricle and correctly identifying normal structures.
As the investigators stress, second harmonic imaging
with echo contrast is particularly helpful in improving
detection of LVT (8 –10).
A prospective comparison of TTEs and DECMRs from multiple centers for detection of LVT
would be welcomed but will likely show that both are
reliable methods if performed well in selected populations. Ella Fitzgerald’s popular 1939 recording says it
well “T’aint what you do (it’s the way that you do it)” and
applies to performance of TTE, DE-CMR, and comparisons of diagnostic tests.
As with any diagnostic test, clearly defining the
clinical indication enhances its predictive value. Highrisk clinical settings for LVT include: 1) stroke,
transient ischemic attack, or systemic embolism;
2) recent myocardial infarction—particularly the first
3 months following anterior infarction; 3) left ventricular aneurysm; and 4) decreased left ventricular systolic performance. For these clinical indications, TTE
REFERENCES
1. Douglas PS, Garcia MJ, Haines DE,
et al. ACCF/ASE/AHA/ASNC/
HFSA/HRS/SCAI/SCCM/SCCT/
SCMR 2011 appropriate use criteria
for echocardiography: a report of the
American College of Cardiology Foundation Appropriate Use Criteria Task
Force, American Society of Echocardiography, American Heart Association,
American Society of Nuclear Cardiology, Heart Failure Society of America,
Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine,
Society of Cardiovascular Computed
Tomography, and Society for Cardiovascular Magnetic Resonance. J Am
Coll Cardiol 2011;57:1126 – 66.
2. Ezekowitz MD, Wilson DA, Smith
EO, et al. Comparison of indium-111
Downloaded From: http://imaging.onlinejacc.org/ on 10/01/2016
should include the basic imaging described here including echo contrast unless findings are unequivocal.
The use of echo contrast is limited by cost and was
undoubtedly affected by the U.S. Food and Drug
Administration’s “black box” warning (13), which may
have inadvertently limited the clinical use of a valuable
adjunct to TTE. The frequency of serious adverse
events reported for perflutren (an echo contrast agent)
should allay any safety concerns (14 –16). Support by
professional societies for echo contrast to improve
overall image quality and accuracy of interpretation
seems appropriate.
The observations by Weinsaft et al. (5) should
influence clinical practice and guide further investigation. When detection of LVT would influence treatment, clinicians should not rely on suboptimal TTEs;
another diagnostic test such as DE-CMR or CT scan
(17) should be performed. The natural history of LVT
with contemporary treatment of acute myocardial
infarction and congestive heart failure is variably reported (18 –21) and the embolic potential of LVT in
various clinical settings continues to be unclear as is
the efficacy of anticoagulation for primary prevention
of embolism, its duration, and endpoint (18,22,23).
Both TTE and DE-CMR could play complimentary
roles in further defining both the incidence and
embolic potential of LVT.
Reprint requests and correspondence: Dr. Richard W.
Asinger, University of Minnesota, Cardiac Rehabilitation
Laboratory, Hennepin County Medical Center, 701 Park
Avenue South, Minneapolis, Minnesota 55425. E-mail:
asing001@umn.edu.
platelet scintigraphy and twodimensional echocardiography in the
diagnosis of left ventricular thrombi.
N Engl J Med 1982;306:1509 –13.
3. Stratton JR, Lighty GW Jr., Pearlman
AS, Ritchie JL. Detection of left ventricular thrombus by two-dimensional
echocardiography: sensitivity, specificity, and causes of uncertainty. Circulation 1982;66:156 – 66.
4. Visser CA, Kan G, David GK, Lie
KI, Durrer D. Two-dimensional
echocardiography in the diagnosis of
left ventricular thrombus: a prospective study of 67 patients with anatomic
validation. Chest 1983;83:228 –32.
5. Weinsaft JW, Kim HW, Crowley
AL, et al. LV thrombus detection by
routine echocardiography: insights
into performance characteristics using
delayed enhancement CMR. J Am
Coll Cardiol Img 2011;4:702–12.
6. Weinsaft JW, Kim HW, Shah DJ, et
al. Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with
systolic dysfunction. J Am Coll Cardiol 2008;52:148 –57.
7. Srichai MB, Junor C, Rodriguez LL,
et al. Clinical, imaging, and pathological characteristics of left ventricular
thrombus: a comparison of contrastenhanced magnetic resonance imaging, transthoracic echocardiography,
and transesophageal echocardiography
with surgical or pathological validation. Am Heart J 2006;152:75– 84.
8. Mansencal N, Nasr IA, Pilliere R, et
al. Usefulness of contrast echocardiography for assessment of left ventricular thrombus after acute myocardial infarction. Am J Cardiol
2007;99:1667–70.
JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 7, 2011
JULY 2011:713–5
9. Thanigaraj S, Schechtman KB, Perez
JE. Improved echocardiographic delineation of left ventricular thrombus
with the use of intravenous secondgeneration contrast image enhancement. J Am Soc Echocardiogr 1999;
12:1022– 6.
10. Weinsaft JW, Kim RJ, Ross M, et al.
Contrast-enhanced anatomic imaging
as compared to contrast-enhanced tissue characterization for detection of
left ventricular thrombus. J Am Coll
Cardiol Img 2009;2:969 –79.
11. Siebelink HM, Scholte AJ, Van de
Veire NR, et al. Value of contrast
echocardiography for left ventricular
thrombus detection postinfarction and
impact on antithrombotic therapy.
Coron Artery Dis 2009;20:462– 6.
12. Asinger RW, Mikell FL, Sharma B,
Hodges M. Observations on detecting
left ventricular thrombus with two dimensional echocardiography: emphasis
on avoidance of false positive diagnoses.
Am J Cardiol 1981;47:145–56.
13. New U.S. Food and Drug Administration prescribing information for
Definity approved October 10, 2007.
Available at: http://www.accessdata.fda.
gov/drugsatfda_docs/label/2007/
021064s007lbl.pdf. Accessed October 20,
2007.
14. Herzog CA. Incidence of adverse
events associated with use of perflutren contrast agents for echocardiography. JAMA 2008;299:2023–5.
15. Main ML, Ryan AC, Davis TE, Albano MP, Kusnetzky LL, Hibberd M.
Acute mortality in hospitalized patients undergoing echocardiography
with and without an ultrasound contrast agent (multicenter registry results
in 4,300,966 consecutive patients).
Am J Cardiol 2008;102:1742– 6.
16. Wei K, Mulvagh SL, Carson L, et al.
The safety of Definity and Optison for
ultrasound image enhancement: a retrospective analysis of 78,383 administered contrast doses. J Am Soc Echocardiogr 2008;21:1202– 6.
17. Tehrani F, Eshaghian S. Detection of
left ventricular thrombus by coronary
computed tomography angiography.
Am J Med Sci 2009;338:167– 8.
18. Osherov AB, Borovik-Raz M, Aronson D, et al. Incidence of early left
ventricular thrombus after acute anterior wall myocardial infarction in the
primary coronary intervention era.
Am Heart J 2009;157:1074 – 80.
19. Rabbani LE, Waksmonski C, Iqbal
SN, et al. Determinants of left ventricular thrombus formation after primary percutaneous coronary interven-
Downloaded From: http://imaging.onlinejacc.org/ on 10/01/2016
Asinger and Herzog
Editorial Comment
tion for anterior wall myocardial
infarction. J Thromb Thrombolysis
2008;25:141–5.
20. Rehan A, Kanwar M, Rosman H, et
al. Incidence of post myocardial infarction left ventricular thrombus formation in the era of primary percutaneous intervention and glycoprotein
IIb/IIIa inhibitors: a prospective observational study. Cardiovasc Ultrasound 2006;4:20.
21. Solheim S, Seljeflot I, Lunde K, et al.
Frequency of left ventricular thrombus
in patients with anterior wall acute
myocardial infarction treated with
percutaneous coronary intervention
and dual antiplatelet therapy. Am J
Cardiol 2010;106:1197–200.
22. van Dantzig JM, Delemarre BJ, Bot
H, Visser CA. Left ventricular thrombus in acute myocardial infarction.
Eur Heart J 1996;17:1640 –5.
23. Stratton JR, Ritchie JL. 111In platelet
imaging of left ventricular thrombi.
Predictive value for systemic emboli.
Circulation 1990;81:1182–9.
Key Words: cardiac magnetic
resonance y echocardiography y
left ventricular thrombus.
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