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Inferior infarction with large nonapical mobile thrombus mimicking myxoma
402
Brief Communications
ferior wall clearly illustrates t h a t resection can be successfully u n d e r t a k e n when the remainder of the ventricle still contracts. In summary, aneurysms of the inferior wall of the left ventricle are rare. Giant aneurysm formation in this region is extremely uncommon. Noninvasive and invasive assessm e n t are needed to yield information critical for further m a n a g e m e n t decisions. Surgical resection of inferior wall aneurysm is technically demanding. However, if the resection is indicated and successfully carried out, both left ventricular volume and function improve significantly, with long-term resolution of congestive h e a r t failure. REFERENCES
1. Meng RL, Najati H. Left ventricular anenrysm; natural history and surgical treatment in cardiac surgery. 2nd ed. Philadelphia: F.A. Davis Company, 1987:53-61. 2. Gorlin R, Klein MD, Sullivan JM. Prospective study of ventricular aneurysm. Mechanistic concept and clinical recognition. Am J Med 1967;42:512-31. 3. Olearchyk AS, Lemole GM, Spagna PM. Left ventricular aneurysm. J Thorac Cardiovasc Surg 1984;88:544-53. 4. Darrett M, Charuzi Y, Davidson RM, Silverberg R, Heng MK, Swan HJC, Corday E. Two-dimensional echo assessment of residual myocardial function and left ventricular aneurysm. [Abstract]. Am J Cardiol 1978;41:406. 5. Gehl L, DePace NL, Kotler MN, Mintz GS, Haaz W, Mundth ED. Two-dimensional analysis of wall motion before and after aneurysectomy. J Cardiovasc Ultrasound 1982;1:211-15. 6. Barrett-Boyes BG, White HO, Agnew JM, Pemberton JR, Wild CJ. The results of surgical treatment of left ventricular aneurysms J Thorac Cardiovasc Surg 1984;87:87-8.
Inferior infarction with large nonapical mobile thrombus mimicking myxoma Erik Kj~iller, MD, H e n r i k Egeblad, MD, and Erik Hjelms, MD. Copenhagen, Denmark
M u r a l t h r o m b i are frequently observed in patients with t r a n s m u r a l anterior acute myocardial infarction (AMI), whereas the prevalence of t h r o m b i is low in other types of AMI.i, 2 Mobile polypoid t h r o m b i ( M P T ) appear to be those with the highest inherent risk of systemic arterial embolism.2, 3 However, the use of thrombus morphology in the prediction of the risk of systemic arterial embolism is of limited value because spontaneous changes of t h r o m b i m a y take place during the course of AMI. 2, 4 Mobile polypoid t h r o m b i are the most infrequent t y p e of thrombus 24 and occur in less t h a n 5% of patients with AMI. 2 T h u s observations made in isolated patients m a y still contribute i m p o r t a n t information about problems encountered in From Medical Department B and the Department of Thoracic Surgery, RT, Rigshospitalet, University Hospital of Copenhagen, Denmark. Reprint requests: Erik Kj~tller,MD, MedicalDepartment F, Herlev H0spital, University Hospital of Copenhagen, DK-2730 Herlev, Denmark. 4/4/17535
February 1990 American Heart Journal
M P T . In this communication we r e p o r t a case of M P T with an unusual appearance and localization, which were factors t h a t led to diagnostic and therapeutic problems. A 41-year-old man, a cigarette smoker (20 per day) with no other predisposition to ischemic heart disease, was admitted to a local hospital with infero-lateral AMI. No thrombolysis was administered. T h e peak C K - M B value was 96 U • 1 - i (normally below 12 U x 1-i). T h e course of t r e a t m e n t was uneventful. Routine echocardiography performed on day 12 showed hypokinesia of the posterior and inferior wall and of the lower and posterior half of the septurn and lateral wall. The remaining left ventricular myocardium was hyperkinetic. T h e r e was no sign of mural thrombus. T h e end-diastolic diameter of the left ventricle was 55 mm, and the fractional shortening was 25 %. An exercise test before discharge showed normal functional capacity and no S T - T changes or angina pectoris. Electrocardiography a t discharge showed major Q waves in leads II, III, and~aVF and minor Q waves in leads V5 to V6. Four and 6 months after the AMI, the p a t i e n t experienced two episodes of sudden severe vertigo, paresthesia in his left arm, and inability to focus his eyes t h a t lasted less than 1 hour. He was seen in our o u t p a t i e n t clinic 2 weeks after the last episode. Electrocardiography and left ventricular wall motion at echocardiography were unchanged. There was no aneurysm, b u t two masses were noted (Fig. 1). One was conical with the base towards the cavity and a diameter of 21/2 to 3 cm. This mass was attached by a slender stalk and was extremely mobile. The other was more polypoid, fingerlike, yet also mobile with a diameter of 1/2 to I cm and a length of 2 to 3 cm. T h e masses were closely related, and both adhered to the infero-posterior wall near the insertion of the postero-medial papillary muscle. Treatm e n t with phenprocoumon was initiated. One month later echocardiography revealed the disappearance of the fingerlike mass. All other findings, including the appearance of the large mobile mass, were unchanged up to 3 months later. Coronary arteriography showed a severe stenosis of the right coronary artery proximal to the crux. The posterior descending branch was filled by collaterals from a normal left coronary artery. A p a r t from minor dizzy spells, no clinical s y m p t o m s t h a t indicated systemic arterial embolism had occurred during anticoagulant treatment. However, the unusual location and persistent appearance of the mass in a 41-year-old p a t i e n t aroused suspicion of a myxoma with embolism to the right coronary artery and to the brain. Open h e a r t surgery with extirpation of the mass and coronary bypass grafting was scheduled. The day before the surgery, 10 months after the AMI, the p a t i e n t complained of vertigo, headache, and reduced sensation in his left arm. Ecbocardiography showed no changes, b u t plasma prothrombin time was 1.4 International Normalized Ratio (therapeutic range, 3.1-2.1). On the day of the surgery, the patient awoke with pareses, partial loss of vision, aphasia, and dysarthria. Computed tomographic scanning of the brain was normal. Carotid artery angiography showed an a b r u p t occlusion of the right internal carotid artery but no signs of arteriosclerosis. Echocardiography showed no definite change of the left ventricular mass. After 6 weeks, the
Volume 119 Number 2, Part 1
Brief Communications
403
Fig. 1. The large conical myxomalike thrombus (T) was protruding towards the apex in diastole and towards the outflow tract in systole (apical long-axis views, left panels). The long-axis views and the parasternal short-axis view (upper right panel) demonstrate the unusual attachment of T (horizontal arrow) at the junction of the inferior wall, the posterior wall, and the septum. AO; ascending aorta; RV, right ventricle; t, minor polypoid thrombus. The M-mode echocardiogram shows hypokinesia of the inferoposterior wall, septal hyperkinesia, and E point septal separation of 1 cm, which reflects the relatively good overall left ventricular function.
neurologic symptoms had remitted to quadrant hemianopsia and dysarthria. Repeated echocardiography was unchanged and open-heart surgery confirmed the findings with respect to localization and appearance of the mobile mass. The mass was extirpated by means of a ventriculotomy, and a bypass graft was performed to the right coronary artery. The postoperative course was uneventful. Histologic examination of the left ventricular mass showed amorphous thrombus material encapsulated in endothelialized connective tissue. There was no sign of myxoma or other tumor tissue. Several studies have shown that thrombi are rare findings in inferior AMI, 1, 2 although they may sometimes occur at the apex, particularly when coexisting Q waves or ischemic ST-T changes are present in the lateral precordial leads. 2 To the best of our knowledge there are, however, no reports on conical mobile thrombi attached at the junction of the septum and the inferior and posterior walls (Fig. 1). The disappearance of the second mass and the attachment
of the masses to the infarcted region of the ventricle favored the. suspicion that the masses were thrombotic in nature. In contrast, the unusual location, late appearance, and behavior of the larger mass in combination with only mild reduction of left ventricular function prompted the consideration of myxoma with initial embolization to the right coronary artery. 5 The occasional occurrence of emboli from persistent MPT, despite implementation of anticoagulants, facilitated the decision to perform surgery.3 Theoretically, the repeated episodes Of transitory ischemia in the right cerebral hemisphere and occlusion of the right carotid artery might have been caused by embolism from an ulcerative carotid artery plaque with later thrombosis. However, the angiographic appearance indicated embolism, and it is likely that the embolic event was a result of the preoperative reduction of the anticoagulant treatment. A qualitatively unchanged echocardiographic presentation of the left ventricular mass was not considered to be in contradiction with embolism from the mass.
February
404
Brief Communications
1990
American Heart Journal
M a n a g e m e n t of patients with M P T is still debatable. Heparin and vitamin K antagonists are probably the first choice of t h e r a p y in most centers, 2, 3 but open-heart surgery may be considered in selected cases. 6 Persistence of a protruding t h r o m b u s with considerable mobility, despite anticoagulant t r e a t m e n t , may be an indication of impending embolism. 3 In this setting, limited myocardial injury with good overall left ventricular function and a low surgical risk may favor the decision of early thrombectomy after healing of the AMI. T h e present report illustrates that clinical and echocardiographic resemblance between M P T and myxoma m a y make surgical intervention m a n d a t o r y in rare cases. REFERENCES
1. Visser CA, Kan G, Lie KI, Denver D. Left ventricular thrombus following acute myocardial infarction: a prospective serial echocardiographic study of 96 patients. Eur Heart J 1983;4: 333-7. 2. Egeblad H. Intracardiac thrombus--systemic arterial embolism. Contribution of echocardiography. Acta Med Scand 1988;(suppl. 730):1-112. 3. Johannesen K-A, Nordrehaug JE, von der Lippe G, Vollset SE. Risk factors for embolisation in patients with left ventricular thrombus and acute myocardial infarction. Br Heart J 1988;60:104-10: 4. Domenicucci R, Bellotti P, Chiarella F, Lupa G, Vecchio C. Spontaneous morphologic changes in left ventricular thrombi: a prospective two-dimensional echocardiographic study. Circulation 1987;75:737-43. 5. Lehrmann KL, Prozan GB, Ullyot D. Atrial myxoma presenting as acute myocardial infarction. AM HEART J 1985;110: 1293-5. 6. Lewin RF, Vidne B, Sclarowsky S, Agmon J. Two-dimensional real-time echocardiographic detection of left ventricular aneurysm associated with mobile pedunculated thrombi. Chest 1980;77:704-6.
Unusual presentation and echocardiographic features of surgically proven nonbacterial thrombotic endocardiUs
Fig. 1. Two-dimensi0nal echocardiograms in the fourchamber view in systole (A) and in diastole (B) demonstrating the large vegetation (v) arising from the tricuspid valve. LA, Left atrium; L V, left ventricle; RA, right atrium; RV, right ventricle.
M o h ' d A. Habbab, MD, M u a y e d A. Al-Zaibag, MD, Akram M. A1-Hilali, MD, and Mohamed R. A1-Fagih, MD. Riyadh, Saudi Arabia
Nonbacterial thrombotic endocarditis (NBTE) is often diagnosed only at p o s t m o r t e m examination. Few reports have described the a n t e m o r t e m two-dimensional echocardi0graphic features of this condition in autopsy-proven casesfl 2 We report an unusual presentation and describe t h e echocardiographic features of a surgically proven case of N B T E in a p a t i e n t with acute leukemia. From the Departments of Cardiology" and Hematology, Riyadh Armed Forces Hospital. RePrint requests: Moh!d A. Habbab, MD, SUNY Health Science Center at Brooklyn, Cardiology Division, 450 Clarkson Ave.--Box 1199, Brooklyn, NY 11203. 4/4/17530
Fig, 1C. Two-dimensional echocardiogram in the shortaxis View at the mitral valve level demonstrates the large vegetation arising:from the tricuspid valve. LV, Left ventricle; R V, right ventricle; V, vegetation.
Brief Communications
ferior wall clearly illustrates t h a t resection can be successfully u n d e r t a k e n when the remainder of the ventricle still contracts. In summary, aneurysms of the inferior wall of the left ventricle are rare. Giant aneurysm formation in this region is extremely uncommon. Noninvasive and invasive assessm e n t are needed to yield information critical for further m a n a g e m e n t decisions. Surgical resection of inferior wall aneurysm is technically demanding. However, if the resection is indicated and successfully carried out, both left ventricular volume and function improve significantly, with long-term resolution of congestive h e a r t failure. REFERENCES
1. Meng RL, Najati H. Left ventricular anenrysm; natural history and surgical treatment in cardiac surgery. 2nd ed. Philadelphia: F.A. Davis Company, 1987:53-61. 2. Gorlin R, Klein MD, Sullivan JM. Prospective study of ventricular aneurysm. Mechanistic concept and clinical recognition. Am J Med 1967;42:512-31. 3. Olearchyk AS, Lemole GM, Spagna PM. Left ventricular aneurysm. J Thorac Cardiovasc Surg 1984;88:544-53. 4. Darrett M, Charuzi Y, Davidson RM, Silverberg R, Heng MK, Swan HJC, Corday E. Two-dimensional echo assessment of residual myocardial function and left ventricular aneurysm. [Abstract]. Am J Cardiol 1978;41:406. 5. Gehl L, DePace NL, Kotler MN, Mintz GS, Haaz W, Mundth ED. Two-dimensional analysis of wall motion before and after aneurysectomy. J Cardiovasc Ultrasound 1982;1:211-15. 6. Barrett-Boyes BG, White HO, Agnew JM, Pemberton JR, Wild CJ. The results of surgical treatment of left ventricular aneurysms J Thorac Cardiovasc Surg 1984;87:87-8.
Inferior infarction with large nonapical mobile thrombus mimicking myxoma Erik Kj~iller, MD, H e n r i k Egeblad, MD, and Erik Hjelms, MD. Copenhagen, Denmark
M u r a l t h r o m b i are frequently observed in patients with t r a n s m u r a l anterior acute myocardial infarction (AMI), whereas the prevalence of t h r o m b i is low in other types of AMI.i, 2 Mobile polypoid t h r o m b i ( M P T ) appear to be those with the highest inherent risk of systemic arterial embolism.2, 3 However, the use of thrombus morphology in the prediction of the risk of systemic arterial embolism is of limited value because spontaneous changes of t h r o m b i m a y take place during the course of AMI. 2, 4 Mobile polypoid t h r o m b i are the most infrequent t y p e of thrombus 24 and occur in less t h a n 5% of patients with AMI. 2 T h u s observations made in isolated patients m a y still contribute i m p o r t a n t information about problems encountered in From Medical Department B and the Department of Thoracic Surgery, RT, Rigshospitalet, University Hospital of Copenhagen, Denmark. Reprint requests: Erik Kj~tller,MD, MedicalDepartment F, Herlev H0spital, University Hospital of Copenhagen, DK-2730 Herlev, Denmark. 4/4/17535
February 1990 American Heart Journal
M P T . In this communication we r e p o r t a case of M P T with an unusual appearance and localization, which were factors t h a t led to diagnostic and therapeutic problems. A 41-year-old man, a cigarette smoker (20 per day) with no other predisposition to ischemic heart disease, was admitted to a local hospital with infero-lateral AMI. No thrombolysis was administered. T h e peak C K - M B value was 96 U • 1 - i (normally below 12 U x 1-i). T h e course of t r e a t m e n t was uneventful. Routine echocardiography performed on day 12 showed hypokinesia of the posterior and inferior wall and of the lower and posterior half of the septurn and lateral wall. The remaining left ventricular myocardium was hyperkinetic. T h e r e was no sign of mural thrombus. T h e end-diastolic diameter of the left ventricle was 55 mm, and the fractional shortening was 25 %. An exercise test before discharge showed normal functional capacity and no S T - T changes or angina pectoris. Electrocardiography a t discharge showed major Q waves in leads II, III, and~aVF and minor Q waves in leads V5 to V6. Four and 6 months after the AMI, the p a t i e n t experienced two episodes of sudden severe vertigo, paresthesia in his left arm, and inability to focus his eyes t h a t lasted less than 1 hour. He was seen in our o u t p a t i e n t clinic 2 weeks after the last episode. Electrocardiography and left ventricular wall motion at echocardiography were unchanged. There was no aneurysm, b u t two masses were noted (Fig. 1). One was conical with the base towards the cavity and a diameter of 21/2 to 3 cm. This mass was attached by a slender stalk and was extremely mobile. The other was more polypoid, fingerlike, yet also mobile with a diameter of 1/2 to I cm and a length of 2 to 3 cm. T h e masses were closely related, and both adhered to the infero-posterior wall near the insertion of the postero-medial papillary muscle. Treatm e n t with phenprocoumon was initiated. One month later echocardiography revealed the disappearance of the fingerlike mass. All other findings, including the appearance of the large mobile mass, were unchanged up to 3 months later. Coronary arteriography showed a severe stenosis of the right coronary artery proximal to the crux. The posterior descending branch was filled by collaterals from a normal left coronary artery. A p a r t from minor dizzy spells, no clinical s y m p t o m s t h a t indicated systemic arterial embolism had occurred during anticoagulant treatment. However, the unusual location and persistent appearance of the mass in a 41-year-old p a t i e n t aroused suspicion of a myxoma with embolism to the right coronary artery and to the brain. Open h e a r t surgery with extirpation of the mass and coronary bypass grafting was scheduled. The day before the surgery, 10 months after the AMI, the p a t i e n t complained of vertigo, headache, and reduced sensation in his left arm. Ecbocardiography showed no changes, b u t plasma prothrombin time was 1.4 International Normalized Ratio (therapeutic range, 3.1-2.1). On the day of the surgery, the patient awoke with pareses, partial loss of vision, aphasia, and dysarthria. Computed tomographic scanning of the brain was normal. Carotid artery angiography showed an a b r u p t occlusion of the right internal carotid artery but no signs of arteriosclerosis. Echocardiography showed no definite change of the left ventricular mass. After 6 weeks, the
Volume 119 Number 2, Part 1
Brief Communications
403
Fig. 1. The large conical myxomalike thrombus (T) was protruding towards the apex in diastole and towards the outflow tract in systole (apical long-axis views, left panels). The long-axis views and the parasternal short-axis view (upper right panel) demonstrate the unusual attachment of T (horizontal arrow) at the junction of the inferior wall, the posterior wall, and the septum. AO; ascending aorta; RV, right ventricle; t, minor polypoid thrombus. The M-mode echocardiogram shows hypokinesia of the inferoposterior wall, septal hyperkinesia, and E point septal separation of 1 cm, which reflects the relatively good overall left ventricular function.
neurologic symptoms had remitted to quadrant hemianopsia and dysarthria. Repeated echocardiography was unchanged and open-heart surgery confirmed the findings with respect to localization and appearance of the mobile mass. The mass was extirpated by means of a ventriculotomy, and a bypass graft was performed to the right coronary artery. The postoperative course was uneventful. Histologic examination of the left ventricular mass showed amorphous thrombus material encapsulated in endothelialized connective tissue. There was no sign of myxoma or other tumor tissue. Several studies have shown that thrombi are rare findings in inferior AMI, 1, 2 although they may sometimes occur at the apex, particularly when coexisting Q waves or ischemic ST-T changes are present in the lateral precordial leads. 2 To the best of our knowledge there are, however, no reports on conical mobile thrombi attached at the junction of the septum and the inferior and posterior walls (Fig. 1). The disappearance of the second mass and the attachment
of the masses to the infarcted region of the ventricle favored the. suspicion that the masses were thrombotic in nature. In contrast, the unusual location, late appearance, and behavior of the larger mass in combination with only mild reduction of left ventricular function prompted the consideration of myxoma with initial embolization to the right coronary artery. 5 The occasional occurrence of emboli from persistent MPT, despite implementation of anticoagulants, facilitated the decision to perform surgery.3 Theoretically, the repeated episodes Of transitory ischemia in the right cerebral hemisphere and occlusion of the right carotid artery might have been caused by embolism from an ulcerative carotid artery plaque with later thrombosis. However, the angiographic appearance indicated embolism, and it is likely that the embolic event was a result of the preoperative reduction of the anticoagulant treatment. A qualitatively unchanged echocardiographic presentation of the left ventricular mass was not considered to be in contradiction with embolism from the mass.
February
404
Brief Communications
1990
American Heart Journal
M a n a g e m e n t of patients with M P T is still debatable. Heparin and vitamin K antagonists are probably the first choice of t h e r a p y in most centers, 2, 3 but open-heart surgery may be considered in selected cases. 6 Persistence of a protruding t h r o m b u s with considerable mobility, despite anticoagulant t r e a t m e n t , may be an indication of impending embolism. 3 In this setting, limited myocardial injury with good overall left ventricular function and a low surgical risk may favor the decision of early thrombectomy after healing of the AMI. T h e present report illustrates that clinical and echocardiographic resemblance between M P T and myxoma m a y make surgical intervention m a n d a t o r y in rare cases. REFERENCES
1. Visser CA, Kan G, Lie KI, Denver D. Left ventricular thrombus following acute myocardial infarction: a prospective serial echocardiographic study of 96 patients. Eur Heart J 1983;4: 333-7. 2. Egeblad H. Intracardiac thrombus--systemic arterial embolism. Contribution of echocardiography. Acta Med Scand 1988;(suppl. 730):1-112. 3. Johannesen K-A, Nordrehaug JE, von der Lippe G, Vollset SE. Risk factors for embolisation in patients with left ventricular thrombus and acute myocardial infarction. Br Heart J 1988;60:104-10: 4. Domenicucci R, Bellotti P, Chiarella F, Lupa G, Vecchio C. Spontaneous morphologic changes in left ventricular thrombi: a prospective two-dimensional echocardiographic study. Circulation 1987;75:737-43. 5. Lehrmann KL, Prozan GB, Ullyot D. Atrial myxoma presenting as acute myocardial infarction. AM HEART J 1985;110: 1293-5. 6. Lewin RF, Vidne B, Sclarowsky S, Agmon J. Two-dimensional real-time echocardiographic detection of left ventricular aneurysm associated with mobile pedunculated thrombi. Chest 1980;77:704-6.
Unusual presentation and echocardiographic features of surgically proven nonbacterial thrombotic endocardiUs
Fig. 1. Two-dimensi0nal echocardiograms in the fourchamber view in systole (A) and in diastole (B) demonstrating the large vegetation (v) arising from the tricuspid valve. LA, Left atrium; L V, left ventricle; RA, right atrium; RV, right ventricle.
M o h ' d A. Habbab, MD, M u a y e d A. Al-Zaibag, MD, Akram M. A1-Hilali, MD, and Mohamed R. A1-Fagih, MD. Riyadh, Saudi Arabia
Nonbacterial thrombotic endocarditis (NBTE) is often diagnosed only at p o s t m o r t e m examination. Few reports have described the a n t e m o r t e m two-dimensional echocardi0graphic features of this condition in autopsy-proven casesfl 2 We report an unusual presentation and describe t h e echocardiographic features of a surgically proven case of N B T E in a p a t i e n t with acute leukemia. From the Departments of Cardiology" and Hematology, Riyadh Armed Forces Hospital. RePrint requests: Moh!d A. Habbab, MD, SUNY Health Science Center at Brooklyn, Cardiology Division, 450 Clarkson Ave.--Box 1199, Brooklyn, NY 11203. 4/4/17530
Fig, 1C. Two-dimensional echocardiogram in the shortaxis View at the mitral valve level demonstrates the large vegetation arising:from the tricuspid valve. LV, Left ventricle; R V, right ventricle; V, vegetation.