Left ventricular thrombus

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor in Chief: M.Umer Tariq [2]

Overview

Left ventricular thrombus is a complication of systolic heart failure and myocardial infarction. Thrombus develops in the presence of Virchow's triad; blood stagnation due to akinesis/hypokinesis, hypercoagulability and endocardial injury. The thrombus may cause strokes and systemic thromboembolism.

Incidence

Left ventricular thrombus occurs less frequently now, with higher rates of performance of primary PCI in the treatment of ST elevation myocardial infarction. The reported incidence is approximately 4-15%. In the absence of revascularization the incidence can be much higher, 20-60%. In heart failure patients the incidence is approximately 11-40%. The annual risk of thromboembolism in patients with ischemic cardiomyopathy is 1.4-12%.

Pathophysiology

Left ventricular thrombus occurs most importantly due to blood stasis around the akinetic segment in the left ventricle. Mobile and protruding thrombi carry the highest risk of embolization.

Diagnosis

Echocardiography is the most common modality used to identify left ventricular thrombus. A transthoracic echo has a sensitivity of about 60% which increases with the use of contrast. Cardiac MRI with gadolinium contrast is the most sensitive and specific diagnostic test, which makes it the gold standard test.

Treatment

Anticoagulation is the main stay of treatment. AHA/ACC guidelines recommend at least 3 months of warfarin therapy and indefinitely if the bleeding risk is low.