Ultrasound Case of the Week #14
If you guessed an intracardiac mass, you're right. The official echo revealed a well formed thrombus jutting into the left ventricle, appearing to be attached to the apex, with the associated wall dyskinetic at the attachment site and….
an ejection fraction estimated to be less than 15% with four chamber dilatation. He also has moderate mitral regurgitation (blue jet) and some tricuspid regurgitation as well (the other blue jet).
Cardiology was consulted due to the pt.’s large LV thrombus, relative hypotension, and poor ejection fraction.
The patient was followed in the hospital to rule out a non-Q wave MI and was concomitantly diuresed. He was noted to have an elevation in troponins with the second set (3.0 ng/mL) and third set ( 4.7 ng/mL) of enzymes. Cardiac catheterization on the 3rd day, however, revealed only a severe episode of acute congestive heart failure and it was felt that the elevated troponins were likely a result of an acute heart failure exacerbation.
Discussion of Intracardiac Masses and Echo
Provided adequate image quality, 2D echo can easily and rapidly visualize several types of intracardiac masses. The etiology of the mass cannot be confirmed however, although its appearance, mobility, attachments, and accompanying cardiac abnormalities can provide some clues.(1)
Differential diagnosis
1.) Thrombus
- Echo-dense, most commonly located in the apex with associated wall abnormalities (sound familiar?) (1).
- Immature thrombus is seen as a filamentous irregular mass and older clot is usually echo-dense and oftentimes mobile.(2)
- Think stasis of flow, low cardiac output, and myocardial injury.(1)
2.) Atrial myoxoma
- Well circumscribed, mobile, most commonly attached to the atrial septum.
3.) Other primary and metastatic tumors
- rhabdomyomas, fibromas, hemangiomas, lipomas, sarcomas, lymphomas, etc.(2)
4.) Technical artifacts
- Lack distinctive borders, no identifiable attachments, no associated wall motion abnormalities, not visualized in all views and depth settings.
5.) Other benign normal variant findings
- Persistent eustachian valve- embryological remnant characterized by thin, linear mobile structure of tissue along junction of IVC and atrium
- Chiari network- embryological remnant characterized by web-like mobile structure in posterior right atrium.
- Others- false chordae tendinae, LVH, hypertrophied papillary muscles, and lipomatous hypertrophy of intratrial septum
6.) Foreign bodies and iatrogenic causes (2)
- catheters, pacemaker leads, prosthetic valves, suture, bullets, and pellets
Treatment of the Intracardiac Thrombus
- treatment has remained unchanged for over a decade with long-term oral anticoagulation being the primary choice.(3,4) Previous studies have shown that although it may be effective, intravenous thrombolysis presents an inappropriate risk or bleeding and embolism.(4) Several authors have proposed surgical intervention for such thrombi. This approach is rarely taken, given the high risks of surgery, in patients with already poor overall health, especially cardiovascular health. (4,5)
References:
1.) Kasper, DL and E Braunwald. Harrison’s Principles of Internal Medicine. 16th edition. New York: McGraw-Hill, 2005.
2.) Fuster, V and RW Alexander. Hurst’s the Heart. 11th edition. New York: McGraw- Hill, 2006.
3.) Van Dantzig JM et al. Left ventricular thrombus in acute myocardial infarction. European Heart Journal (1993):1640-1645.
4.) Meurin, P et al. “Treatment of left ventricular thrombus with a low molecular weight heparin.” International Journal of Cardiology (2005) 98:319-323.
5.) Nil M et al. Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases. Annals of Thoracic Surgery (1998) 46:396-400.
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