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CLINICAL RESEARCH: CARDIAC IMAGING

Detection of Left Ventricular Thrombus by Delayed-Enhancement Cardiovascular Magnetic Resonance

Prevalence and Markers in Patients With Systolic Dysfunction

Jonathan W. Weinsaft, MD^_*,, Han W. Kim, MD^_*,, Dipan J. Shah, MD^_*,, Igor Klem, MD^_*,, Anna Lisa Crowley, MD^_*,, Rhoda Brosnan, MD^_*,, Olga G. James, MD^_*,, Manesh R. Patel, MD^_*,, John Heitner, MD^_*,, Michele Parker, MS, RN^_*, Eric J. Velazquez, MD, Charles Steenbergen, MD, PhD, Robert M. Judd, PhD^_*, and Raymond J. Kim, MD^_*,,_*

^_* Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina
Department of Medicine, Duke University Medical Center, Durham, North Carolina
Department of Pathology, Duke University Medical Center, Durham, North Carolina
Nashville Cardiovascular Magnetic Resonance Institute, Brentwood, Tennessee.

Manuscript received September 6, 2007; revised manuscript received February 6, 2008, accepted March 4, 2008.

^_* Reprint requests and correspondence: Dr. Raymond J. Kim, Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center Box 3439, Durham, North Carolina 27710. (Email: raymond.kim{at}duke.edu).

Objectives: This study sought to assess the prevalence and markers of left ventricular (LV) thrombus among patients with systolic dysfunction.

Background: Prior studies have yielded discordant findings regarding prevalence and markers of LV thrombus. Delayed-enhancement cardiovascular magnetic resonance (DE-CMR) identifies thrombus on the basis of tissue characteristics rather than just anatomical appearance and is potentially highly accurate.

Methods: Prevalence of thrombus by DE-CMR was determined in 784 consecutive patients with systolic dysfunction (left ventricular ejection fraction [LVEF] <50%) imaged between July 2002 and July 2004. Patients were recruited from 2 separate institutions: a tertiary-care referral center and an outpatient clinic. Comparison to cine-cardiovascular magnetic resonance (CMR) was performed. Follow-up was undertaken for thrombus verification via pathology evaluation or documented embolic event within 6 months after CMR. Clinical and imaging parameters were assessed to determine risk factors for thrombus.

Results: Among this at-risk population (age 60 ± 14 years; LVEF 32 ± 11%), DE-CMR detected thrombus in 7% (55 patients) and cine-CMR in 4.7% (37 patients, p < 0.005). Follow-up was consistent with DE-CMR as a better reference standard than cine-CMR, including 100% detection among 5 patients with thrombus verified by pathology (cine-CMR, 40% detection), and logistic regression analysis testing the contributions of DE-CMR and cine-CMR simultaneously, which showed that only the presence of thrombus by DE-CMR was associated with follow-up end points (p < 0.005). Cine-CMR generally missed small intracavitary and small or large mural thrombus. In addition to traditional indices such as low LVEF and ischemic cardiomyopathy, multivariable analysis showed that increased myocardial scarring, an additional parameter available from DE-CMR, was an independent risk factor for thrombus.

Conclusions: In a broad cross section of patients with systolic dysfunction, thrombus prevalence was 7% by DE-CMR and included small intracavitary and small or large mural thrombus missed by cine-CMR. Prevalence increased with worse LVEF, ischemic etiology, and increased myocardial scarring.

Key Words: cardiovascular magnetic resonance • delayed enhancement imaging • thrombus

Abbreviations and Acronyms   CMR = cardiovascular magnetic resonance   CVA = cerebrovascular accident   DE-CMR = delayed-enhancement cardiovascular magnetic resonance   LV = left ventricle/ventricular   LVEF = left ventricular ejection fraction   TI = inversion time   TIA = transient ischemic attack

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