Figures’ legend
Figure 1. Typical example of left ventricular thrombosis assessment by dedicated cardiac magnetic resonance after anterior myocardial infarction.
Patient example. Panel A: Patients with transmural anterior infarction with older mural thrombus (low signal intensity in T1 in cine cardiac). Panel B, C: acute protruding thrombus in the left ventricular apex (yellow arrow) showing high signal intensity on T1. Panel D: phase sensitive contrast-enhanced magnetic resonance images. Panel E: contrast-enhanced magnetic resonance images: note that thrombus appears black on long inversion time (T1).
Figure 2. Different morphological left ventricular thrombi aspects detected by transthoracic echocardiography.
Panel A: 4-chamber apical view showing a left ventricular mural thrombus visible as a minus image (asterisk) because of contrast agent. Panel B: a protruding left ventricular thrombus visualized before (arrow) and after contrast injection (asterisk). Panel C: a large protruding and free mobile left ventricular thrombus before (arrow) and after contrast injection (asterisk).
Figure 3. Left ventricular apical thrombus detected by echocardiography 15 days after acute anterior myocardial infarction.
Panel A: 4-chamber and 2-chamber apical views showing a large protruding LV apical thrombus (asterisk) in an akinetic LV apex. Note soft density and irregular shape typical of recent thrombus Panel B: after contrast injection, the thrombus is visible as a minus image (asterisk). Panel C: full volume RT3D apical view oriented from the LV apex, shows the spatial definition of LV thrombus. Panel D: multislice multiplane view of LV apex with thrombus attached to the apical septal and apical inferior segments. Panel E: follow-up echocardiogram after 3 months of anticoagulant therapy showing almost complete resolution of the apical thrombus but residual shallow mural thrombus with smooth and hyperechogenic surface visible in the apical 2 chamber view (arrow) in the akinetic LV apex. Data on the embolic avoidance and subsequent antithrombotic management in patients who did not achieve total LVT regression are limited or lacking.
Figure 4. Transthoracic echocardiography-based flow chart for guiding LVT management after anterior myocardial infarction. Note that for many decision-making there is no scientific evidence. Therefore, the proposed algorithm is inevitably, for the most part, based on the opinion and clinical practice of the authors.
WMSI: wall motion score index; LVT: left ventricular thrombus; AC: anticoagulation therapy; TTE: transthoracic echocardiography; LV: left ventricle; SEC: spontaneous echo-contrast.