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Real-time 3D echocardiographic evaluation of left ventricular thrombus — A live case
A Nemes, WB Vletter, FJ ten Cate
A Nemes*
WB Vletter
FJ ten Cate
Department of Cardiology, Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands
* Dr. Attila Nemes is a visiting fellow from the University of Szeged (Hungary) and is supported by the Eötvös Hungarian State Fellowship and the Research Fellowship of the European Society of Cardiology
Correspondence to: F.J. ten Cate
Department of Cardiology, Room Ba304, Thoraxcentre, Erasmus Medical Centre, PO Box 2040, 3000 CA Rotterdam, the Netherlands
E-mail: f.j.tencate@erasmusmc.nl
We present a case of a 46-year-old woman who was referred to the Thoraxcentre of the Erasmus Medical Centre in Rotterdam with left- and right-sided cardiac decompensation. Her medical history started in 1996 with signs of dilated cardiomyopathy. Coronary angiography showed normal coronary arteries. Type 2 diabetes mellitus, arterial hypertension, chronic obstructive pulmonary disease, sleep apnoea syndrome and sarcoidosis were also present. At the time of admission, the ECG showed sinus tachycardia with left- and right-sided atrial enlargement with left bundle branch block pattern. Chest X-ray showed cardiomegaly with signs of cardiac decompensation. On two-dimensional transthoracic echocardiography (2DTTE) enlarged atria were found. Also severe mitral regurgitation and impaired ventricular function were noted. A mobile thrombus, 25x7x7 mm in size, was demonstrated between the papillary muscles of the mitral valve in the lateral wall (figures 1A and B).
| Figures 1A and B. Two-dimensional echocardiography shows a thrombus in the lateral wall. |
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For better visualisation, real-time three-dimensional echocardiography (RT3DE) was performed, which showed intensive motion of the propeller-like thrombus (figures 2A and B).
Because of persistent heart failure despite oral diuretic therapy, the poor left ventricular function and nonsustained ventricular tachycardias, a cardioverter defibrillator was implanted. Heart transplantation was offered, but was refused by the patient. Coumarin was started as oral anticoagulant.
For RT3DE, a Philips Sonos 7500 ultrasound system (Philips, Eindhoven, the Netherlands) equipped with software for RT3DE with a 2- to 4-MHz matrix, phased-array scanner was used. For the 3D analysis, a TomTec 4D Echo 5.3 workstation (TomTec, Inc., Unterschleissheim, Germany) was used.
Substantial mortality can be caused by embolic complications of intracardiac thrombi. Two-dimensional transthoracic echocardiography is the reference technique for the diagnosis of left ventricular thrombi. Conventional 2DTTE is able to show only one slice of a thrombus; its spatial position cannot be perfectly clarified. For a better spatial evaluation, not only location, but also the extent can be demonstrated using RT3DE. One case of an apical left ventricular thrombus and its morphology could be fully evaluated in three dimensions by RT3DE.1 RT3DE would be beneficial in understanding the current spatial status of left ventricular thrombus and to obviate the need for further semi-invasive procedures.1-3
This report illustrates the potential of RT3DE for better characterisation of location and extent of a left ventricular thrombus.
References
- Sinha A, Nanda NC, Khanna D, Dod HS, Vengala S, Mehmood F, et al. Morphological assessment of left ventricular thrombus by live three-dimensional transthoracic echocardiography. Echocardiography 2004;21:649-55.
- Chamoun AJ, McCulloch M, Xie T, Shah S, Ahmad M. Real-time three-dimensional echocardiography versus two-dimensional echocardiography in the diagnosis of left ventricular apical thrombi: preliminary findings. J Clin Ultrasound 2003;31:412-8.
- Ahmad M, Xie T, Chamoun AJ, McCulloch M, Shah S. Images in cardiovascular medicine. Real-time three-dimensional echocardiography with real-time volume rendering in assessment of left ventricular apical thrombi. Circulation 2002;106:e53.
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