Chapters Transcript Video Case Study in Left Ventricular Thrombus Hi. Uh good morning, everybody. Thank you for joining us on a Saturday morning and thanks for giving us a chance to discuss these things. As the last speaker on an imaging conference, it's usually easier because everybody has done the hard work. They've introduced the concepts and we just have to summarize it now. So um let's get moving. So left ventricular uh So I've divided this presentation into summarizing what we offer and what the strengths and the weaknesses of each of the studies are. And then in a case based approach, we will try to build up on the concept of uh which study and when it comes into play. So the images uh the imaging studies that we offer at center are wide. We have transthoracic echo, we have nuclear stress test, we have CT A MRI spec tees. And the question when we're rounding or on the hospital is which do I offer? When do I offer it? And when do I need more than one? Because we need to be cognizant of cost timing and patient comfort as well. So, echocardiography, this is the easiest we do it um every day all over the hospital in uh most patients, there's a very high frame rate, we get very good pictures. Um It's high, highly available at all the hospitals. Um The shortcomings are basically it can be limited by the body habitus or the patient positioning and sometimes if there's post op states there's pneumothorax or other issues. So that's one of the main limitations of echo, cardiac ct. This is an up and coming field. Uh Doctor Cohen spoke very nicely about it. Um There are a lot of strengths. Um It's very good for assessing the anatomy. There's a very high spatial resolution, it's a quick study. Um The weaknesses of course are uh involved radiation, it's X rays. Um we can acquire videos using CTAs. However, the amount of X ray radiation exposure becomes um uh very high as we try to do more and more videos of things. The contrast use can be limiting factor for patients who have CKD heart rates and rhythms can also be a limiting factor. If um uh patients have a FB or uh a lot of PV CS, it can lead to a lot of artifacts. Next, we have cardiac MRI. This works not on the principles of x rays, but of magnet magnetism. Um The strength uh of cardiac MRI are we can, it allows us to characterize tissue, we can differentiate between thrombus masses, uh different types of structures, intracardiac, extracardiac, there's a very high spatial resolution, we can acquire a 3D movie without exposure to radiation contrast is safe in most patients. Even with renal dysfunction. In the past, we used to say there's a high risk of NSF but those uh studies, uh more studies uh since that time have shown that most of the neo agents are pretty safe. The weaknesses are that we need to really choose the right patient. Um Effectively most of our cardiac patients, the main presentation is always shortness of breath. So what do we do when we try to do an MRI, we lay them flat on a table, put them in a narrow chamber and tell them to hold their breath every 30 seconds. That's kind of difficult if you have heart failure. So, image acquisition in choosing the right patient is always paramount whenever we're deciding the right study, the most common myth that's evident in the community is that, hey, my patient has a pacemaker. I can't uh I can't get an MRI. That's really not true. There were studies called one of the major trials called the Magna Safe Study. And in that a lot of patients with IC DS and devices were evaluated and it's mostly safe when done in the right fashion. So we can do patients who have IC DS or pacemakers. And it's a case by case determination with discussion with your cardiologist, nuclear stress tests. We offer these and we order quite a few of them. They have a very large role in patient care. Um However, not for today's discussion regarding LV thrombus, we do uh require sometimes pets, stress pets testing. But that's a different discussion as well as we'll get into it. So when do I order each of these tests? And do I need more than one? So the answer is the more compli complex your patient is the higher probability of needing more than one strap. Um More than one modality and this was discussed in European Heart Journal uh uh a couple of years ago, if you feel that you need more than one test, talking to your imaging specialist will probably be the right way because not only can we help you choose the right test, but we can also protocol the right test in a fashion that will get us the answer effectively. What we try to do is answer a question that's um a conundrum for the clinical team, what's going on with the patient and how do we help the patient? And that's where a discuss team discussion always comes into play. So the steps to the get uh get the right answer is what is the clinical uh question? Do I need to define the anatomy, the function, the structure or do I need to have tissue characterization? Is there one best test that can answer all the questions were the limitations in the clinical scenario? And then the other considerations are ob obviously the patient considerations, the turnaround time of test and the availability and the patient uh characteristics. So let's discuss a few cases. So the first case is basically a 50 year old male who was a prior smoker was a diabetic has since been controlled. And an interior led in for in 2017, he was lost to follow up. And in 2023 he had finally decided to establish care again and he had an outpatient echocardiogram that was performed. And um let's get, so I don't have a mouse, I can't play these, but these are all playable videos. Is it possible to play them somehow? Ok. There we go. So that's the outpatient echocardiogram that was done. Um And we can have a conversation about this. Does anyone feel that um there's anything sinister going on in this picture? So we see this artifact, the near field clutter artifact very commonly towards the apex. Um However, sometimes there can be things hiding in the apex that we don't really see. Um an echo, uh an external cardiologist read this study and said the apex is a kinetic rightly. So, however, it didn't question what we're seeing at the apex and it was left um without further discussion. Now, uh three months later, um uh the patient presented to the er with abdominal pain, nausea, vomiting, the abdomen was tense on examination and it was guarding on palpation. We know something bad is going on whenever the radiologist puts an arrow sign in your CT scan. That's never a good thing. So, the arrow sign in this basically shows an embolic uh an embolization into the one of the eccentric vessels. And on the right side, we see pneumatosis of the small bowel as well. That's a bad thing. Could it have been prevented? Probably. So. So what did we do next? We got, we once again, all these are c so if we can play them once again, a simple two ML of definity solved the question. There was there was a large uh apical thrombus and effectively the patient uh did well. After 100 MLS, uh 100 CCS of small bowel resection, the thrombus resolved with anticoagulation, which could have been done on an outpatient basis and this was an avoidable com uh complication had the echocardiographer mentioned that there was possibly an artifact or a thrombus and we require some um contrast for better delineation. So, proceeding on to the next patient um that brings us to case too. So this is a build up on the concept of a contrast evaluation in an echocardiogram. So, a patient with idiopathic idiopathic cardiomyopathy had an I CD heart failure with recovered ef in the past end stage renal disease status, post transplant, uh diabetic, admitted to the hospital for dysnea and exertional chest pain, which was a five days duration. This had happened after about 10 years of her transplant uh for 10 years, she had done fine. So the uh the echocardiogram effectively showed an a reduced lvef dilated left ventricle monitor to severe mi regurgitation. A large complex independently mobile mass and a second large mass in the right atrium. I think the most, um, dreadful thing for an imaging cardiologist is to get a call from an advanced or a senior ecotech that says, hey, can you please look at these pictures? I think there's something wrong. So if we can play these pictures, uh we will see what that something wrong was. So on the left hand side, we see quite a bit of Mr there and just off the top, we can see that the posterior leaflet is not really moving well. And that's probably what's causing some of the mitral regurgitation in the right panel. The uh uh the sonographer administered some uh contrast and these were the pictures that she acquired. So there's a large mass, some uh there's a large mass that lb is dilated, it's dysfunctional and the question becomes, what is the mass? So with there's multiple techniques that we can use to try to identify what the mass is. We can use. Uh perfusion imaging. We can use flash perfusion imaging where basically we destroy the definitive bubbles with high energy and watch them recirculate to see if the mass is vascular or avascular. Sometimes those things can help. However, if there's a lot of thrombus or fibrosis around the mass, that kind of captures the contrast bubbles and prevents us from doing some of those things. So the question becomes, what do we do next? So um hm can we go to the next slide somehow? I OK. There we go. So what we did was 3D imaging with TEE because we really wanted to look at this mass, how it was playing out in the left rle where its attachments were and whether it was really dangerous or what we would want to do about it. So let's play that picture and look at it together. So just by looking at that picture, we know that uh it's probably uh this mass or this lesion is probably encasing the papillary muscles. It looks like it's collapsing into the LVOT and it's also adherent to the anterior papillary muscle. So the questions for the cardiology team uh were do we do heparin, do we do TP A do we? Is it really a thrombus? Could it be something more? How do we differentiate? So once again, the patient characteristics come into play, the patient has ESRD uh post transplant and once again, has really bad renal function. The patient also has an I CD with multiple leads in the heart. So what would be the next best study? And how do we differentiate what this is before proceeding on with advanced imaging? The question is how can we help the patient? So we spoke to the surgeon, what information do you need and how can we help you decide what to do for the patient. So the surgeon basically said, prove to me that this is not cancer and I will take it out if it needs to come out, we will take it out. But first, you have to prove to me that this is not a malignancy that uh that has spread. So the question is, is this a cancer or is it a benign mass? We need tissue characterization. We cannot get an MRI because of the abandoned leads. And our radiologist said we can't give contrast for this anyway. So the effective study, what we did was a pet scan. If the mass was a metabolically active, we would see it light up on the pet scan. We did not and there was no signs of cancer. So the surgeon, we went back to the surgeon, hey, this is not a cancer. Can we take it out? And we did so on surgical excision and biology. See the revelation was that this was a calcified uh thrombus that had been there for a very long time and it was not going to resolve with Heparin, it was not going to resolve with TP A. So effectively, multiple studies were necessary to figure out how to help this patient. And physiologically once we took uh mass out the preload for the patient improved, the LVEF improved because of the resection. The mitral regurgitation also improved. We studied it with tee in the or and we didn't have to do a mitral valve um surgery. The patient did well, she was discharged home uh post op day seven without any complications. So let's proceed to. Case number three, a case uh case number three is a patient with acute chest pain, shortness of breath who was transferred to us from an outlying facility. She had just undergone complex right, coronary artery intervention, which is complicated by coronary dissection approximately three months prior to this presentation, an echocardiogram was performed. It revealed a large basal uh to make inferolateral aneurysm with the mural thrombus. There was also a circumferential pericardial effusion. So the question for the uh imaging team was why is she having pain? Is it an uh is it an ischemic event? Is it a pseudoaneurysm? Is it a true aneurysm? What's the size of the thrombus? And where does it extend? The right test would demonstrate the anatomy uh evaluate for the chest pain, find out about the lbef. So what we decided after the echocardiogram is we probably need both CT and MRI in this case and we'll see why. So if we can play these pictures uh on the left hand panel, we have AC T scan that basically shows the aneurysm uh uh uh in its anatomy. However, the thrombus is not that well delineated on this study. On the right hand side, we proceeded on with an MRI and that actually helps us answer exactly how much of an infarct burden did she have in that region where the thrombus is and why she's been having chest pain. If we look on the outer aspect of the heart, the pericardium is actually enhancing or takes up gadolinium. That means the pericardium is uh scarred. Now, this can be scar or this can be acute inflammation. We cannot tell on the basis of this picture, but we have to correlate it with the patient's presentation. She's having chest pain, we have pericardial enhancement. The probability is that there's acute pericarditis to explain her chest pain. There's a thrombus in there and that region in that uh aneurysmal sac is all dead myocardium. So what do we do next? We take her to the or we did an aneurysm resection, we took out the thrombus and um repaired the left ventricle and she did not need mitral valve surgery because once the geometry was re uh repaired, her mitral valve coop did well. So um those were three cases and um now we've already discussed these findings. So we'll move on to the fourth bonus case. Now, this is a bonus case because this uh demonstrates that not only is it important to decide what modality to use but also within the modality, the right protocol can actually help your patients significantly. So it's very important to talk to your radiologist or imager to decide. Hey, I'm ordering this test. What do I need to do with this test to answer the relevant clinical uh question. So this is a 50 year old lady who has diabetes, hypertension hyperlipidemia. She had ongoing nicotine abuse. Um Her left ventricle was thick because of uncontrolled hypertension and she presented repented to the hospital uh 24 hours after she had had a semi that was not revascularized because of a very diffused, arthritic obtuse marginal vessel. The ongoing uh chest pain. She had been counseled that, hey, you will have chest pain because we didn't revascularize. Please take some nitro and over the period of time, once the medications kick in and your blood pressure resolves your chest pain should get better. So she says I took the night through as counseled, I've almost passed out now in Iowa during the winter, we have snowstorms. So it was fortunate that this lady uh was from a very far away place from our hospital and she had decided to spend the night within the city because there was a blizzard coming and the three hour drive home would have been difficult to manage. So when she almost passed out after this overnight discharge from the hospital, her daughters brought her back to the hospital, something is wrong. So, as a cardiologist, our mind runs, we think of the worst and we hope for the best. So, what's going on? Is it possibly a reinfarction? Could there be an effusion, a tempo? Could it be a dissection from her uh uh recent angiogram? Could it be a complication of M I? Could it be a BS D? Could it be a papillary muscle rupture? Could it be myocardial rupture? So once again, the framework of evaluation was this is an emergent situation. We need rapid testing that is very easily and readily available. And the testing needs to have high sensitivity and specificity for the etiologies that we want to consider a transthoracic echocardiogram like we discussed is very easily acquirable. Can we combine it with other studies to try to answer the question? Yes, we can get AC T A plus att E to rule out most of these, we can do a tee which would require sedation and in a hypertensive patient may not be the best choice. So we decided to proceed with the CT A uh which was readily available in the er now the question becomes, do we need some specific protocol on the CT to answer the question? So, uh the way we planned the CT was we did a noncontrast study followed by a contrast study and we'll see why um if we can play these slides, uh they are a side to side assessment of a noncontrast CT and a contrast enhanced CT. So on the noncontrast and the contrast enhanced, we see some fluid accumulation around the uh myocardium. Um I'm sorry, maybe we can put it on repeat um or maybe we can display it again. Um So there's some fluid accumulation around the heart and as we keep going down, we can go back one frame if we can go pause it one frame higher. There's actually a streak of contrast on the um lateral wall that we see on the contrast enhanced CT. Can we pause here, please? Uh Sorry, that's OK. I I didn't have um my mouse but effectively looking on the right hand panel on the lateral wall, you will see a streak of contrast going from the left ventricle into the pericardium. Now, if we just had the contrast enhanced images, we wouldn't be able to tell whether this is old calcification, whether there is milan calcification that the patient has. However, having the contrast enhancement, uh however, having the noncontrast phase basically helps us that this is not calcium. This is in fact, contrast extravasation from the left ventricle into the pericardium and that's basically a perforation. The patient was taken to the or and she underwent a patch repair of this defect and she in fact uh got discharged on the first of the New Year and she did, she had a great outcome. So planning the right study in the right fashion can also go a long way in the care of patients. So, um in summary, the question that needs to be answered defines what test we should be using. The questions can be functioned, it can be valve assessment, it can be viability assessment, it can be coronary artery disease, it can be prosthetic valve assessment. It can be a patient with congenital heart disease. But the first message I have is planning a complex uh study for a complicated patient. Begins with what question am I trying to answer to get the most um information out of that test? So this is a video if we can play it. Um It's on youtube. I don't know if we can play it. Um I stole it from doctor Bet from the Mayo Clinic and the tool, a tool which is not appropriately applied will not result in the desired um results. Um It's ok if we can play it, it's just a funny clip. Um um And um now I can't go to the next one. Ok. That's ok. Um And the last slide is basically just a thank you. And um if you have any questions, you will always find one of us in the hospital and uh we will always be more than happy to look at pictures to answer any questions to discuss anything with you. Um Just give us a call. I call it the bat cave because it's very dark downstairs. But uh please uh reach out to us and we're more than um available to help. Thank you. Published November 13, 2024 Created by Related Presenters Manik Veer, MD Cardiology View full profile
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