- Email: [email protected]
Surgical treatment of giant left ventricular apical thrombus diagnosed with contrast echocardiography in patient with previous anterior myocardial infarction
Available online at www.sciencedirect.com
Journal of Cardiovascular Echography 22 (2012) 37–39 www.elsevier.com/locate/jcecho
Case report
Surgical treatment of giant left ventricular apical thrombus diagnosed with contrast echocardiography in patient with previous anterior myocardial infarction Rodolfo Citro *, Antonio Panza, Marco Mirra, Lucia Tedesco, Roberta Giudice, Chiara Paolillo, Roberto Ascoli, Antonio Longobardi, Emanuele De Ruberto, Severino Iesu, Giuseppe Di Benedetto ‘‘Heart’’ Department, ‘‘San Giovanni di Dio e Ruggi d’Aragona’’ University Hospital, Salerno, Italy Received 7 December 2011; accepted 9 January 2012; available online 4 February 2012
Abstract Introduction: We report a case of a 66-year-old man with previous anterior ST-elevated myocardial infarction, treated with primary percutaneous coronary intervention and insertion of drug eluting stent on the left anterior descending coronary artery, and left ventricular (LV) apical aneurysm due to no-reflow. After 2 months follow-up contrast echocardiography allowed to detect giant apical LV thrombosis and to exclude impending LV wall rupture. Anticoagulant oral therapy failed to dissolve the thrombus. Aneurismectomy with left ventricular remodeling and excision of the thrombus was performed successfully and the patient was discharged in good condition. Conclusions: Contrast echocardiography was fundamental in diagnosis of LV thrombus excluding an impending LV wall rupture and to guide treatment. # 2012 Societa` Italiana di Ecografia Cardiovascolare. Published by Elsevier Srl. All rights reserved. Key words: Myocardial infarction; Contrast echocardiography; Intraventricular thrombus; Left ventricular aneurism; Cardiac surgery.
Riassunto: Escissione chirurgica di trombo gigante in apice del ventricolo sinistro diagnosticato con ecocardiografica con mezzo di contrasto in paziente con pregresso infarto miocardico anteriore Introduzione: Riportiamo il caso di un paziente di 66 anni con precedente infarto miocardico anteriore con sopraslivellamento del tratto ST, trattato con angioplastica primaria e impianto di stent medicato su arteria discendente anteriore della coronaria sinistra, e aneurisma dell’apice del ventricolo sinistro secondario ad assenza di riperfusione adeguata (no-reflow). Al controllo dopo 2 mesi, l’ecocardiografia con mezzo di contrasto ha permesso di riconoscere un trombo murale di notevoli dimensioni localizzato in corrispondenza di aneurisma dell’apice del ventricolo sinistro e, contestualmente, di escludere una rottura di parete miocardica. Il trombo e` stato resistente alla terapia anticoagulante. Il paziente e` stato sottoposto a intervento chirurgico di aneurismectomia con trombectomia piu` plastica del ventricolo sinistro, e dimesso dopo 7 giorni senza complicanze e in buone condizioni generali. Conclusioni: L’ecocardiografia con mezzo di contrasto e` stata fondamentale nella diagnosi di trombosi ventricolare sinistra, escludendo una possibile rottura di parete, e nel guidare il trattamento. # 2012 Societa` Italiana di Ecografia Cardiovascolare. Pubblicato da Elsevier Srl. Tutti i diritti riservati. Parole chiave: Infarto del miocardio; Ecocardiografia con mezzo di contrasto; Trombo intraventricolare; Aneurisma del ventricolo sinistro; Chirurgia del cuore.
1. Case report We report a case of a 66-year-old man admitted to our Department with chest pain onset 5 hours before due to anterior
* Corresponding author. E-mail address: [email protected] (R. Citro).
ST-elevated myocardial infarction. Patient underwent primary percutaneous coronary intervention (PCI) and implantation of a drug eluting stent (DES) in the middle left anterior descending coronary artery (LAD). After the procedure TIMI flow 1 on LAD was detected (no-reflow). ST-segment elevation persisted in the anterior precordial leads. Transthoracic echocardiography (TTE) showed left ventricular (LV) enlargement and reduced ejection fraction (EF; 45%). Wall motion analysis
2211-4122/$ – see front matter # 2012 Societa` Italiana di Ecografia Cardiovascolare. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.jcecho.2012.01.002
[(Fig._1)TD$IG] 38
R. Citro et al. / Journal of Cardiovascular Echography 22 (2012) 37–39
Fig. 1. a, b. Transthoracic echocardiography, apical four chambers view. a) Mural thrombus in left ventricular aneurism can be appreciated. b) Left ventricular opacification after SonoVue injection. Large thrombus appears as a contrast defect in apex.
[(Fig._2)TD$IG]
revealed akinesis of the apex and the mid segments of interventricular septum and ipokinesia of the mid anterior wall segment with normal contractility of the remaining LV wall. Furthermore, mild pericardial effusion was observed. Patient was discharged after 8 days with beta-blockers, ACE-inhibitor, aspirin, clopidogrel and statin.At 2 months follow-up patient was asymptomatic, ECG was unchanged, TTE showed further enlargement of LV secondary to unfavorable remodeling and aneurismal evolution of the apex with further reduction of LV EF (40%) and no signs of increment of LV filling pressure. Giant apical thrombus (34 mm x 71 mm) adherent to the apex was detected. The TTE was not able to clarify the relationship between the myocardial wall and the giant thrombus (Fig. 1a). Pericardial effusion was unchanged. In order to rule out covered, impending rupture of myocardial wall, cardiac magnetic resonance imaging (CMRI) was proposed. Unfortunately, the patient refused it due to claustrophobia. For this reason, contrast echocardiography by using SonoVue (Bracco Imaging, Italy) as contrast agent was performed with Sequoia 512 (Siemens, Mountain View, California, USA).
Echocardiographic machine was set for LV opacification (Cadence, Contrast Pulse Sequence; second harmonic 1.5 MHz, low mechanical index = 0.3, gain = 16 dB, dynamic range = 50 dB, depth = 12-14 cm, delta = 3, post proc S1/0/1/3 and focus toward apex). After bolus injection with syringe pump of 2 mL of SonoVue (followed by bolus of 5 ml of physiologic solution) an apical thrombus, visualized as a contrast defect in the cavity with no perfusion of microbubbles in the context of mass and into the pericardial space, was appreciated (Fig. 1b). On these grounds oral anticoagulant therapy was started. After 15 days, despite an optimal INR, the thrombus appeared unchanged. Surgical excision of the LVaneurism and thrombus was planned. Cardiopulmonary bypass was established by aortic and single venous cannulation through the right atrium appendage, and the heart was arrested with antegrade cold blood cardioplegia. At inspection no epicardial tearing was appreciated. A 4 cm long left ventriculotomy was performed, 3 cm away and parallel to the distal third of the LAD. After the incision, a 4 x 2 cm friable mass with an irregular surface was detected in the LV apical aneurysm and
Fig. 2. a, b. a) Left ventriculotomy shows a giant apical thrombus with a sucker tip inserted through it. b) thrombus removed.
R. Citro et al. / Journal of Cardiovascular Echography 22 (2012) 37–39
the diagnosis of giant apical thrombus was confirmed (Fig. 2a,b). Patient underwent aneurysmectomy and thrombectomy and ventriculoplasty with a dacron patch insertion according to the Dor technique1. The patient was weaned off cardiopulmonary bypass uneventfully. Postoperative TTE revealed reduced LV volume and a normal LVEF (60%) with mild diastolic dysfunction (abnormal relaxation). Patient was discharged after 7 days in good condition under anticoagulation therapy.
2. Discussion LV thrombi are usually associated with myocardial infarction with an incidence varying between 5% and 28%2. However thrombi can be detected also in other conditions characterized by contraction abnormalities and severe reduction of LV systolic function such as dilated cardiomyopathy, myocarditis, and tako-tsubo cardiomyopathy3. Due to high risk of embolization early detection of ventricular thrombi is fundamental to prevent cerebral or peripheral infarction. During last decade with the increasing practice of primary PCI for STEMI, the incidence of LV thrombi after myocardial infarction is significantly reduced4. However patients with noreflow are at high risk of unfavorable remodeling and aneurismal formation being prone to develop intraventricular thrombi5. In clinical practice TTE by using second harmonic imaging is the most used diagnostic tool to detect LV thrombus with sensitivity and specificity of 95% and 86%, respectively6,7. In case of suboptimal acoustic windows contrast agents in order to better visualize LV cavity can be used. Contrast echocardiography improves visualization of endocardial borders and allows the detection of mural thrombus8. Furthermore, it can be used to unmask artefacts mimicking LV thrombi. However, contrast-enhanced CMRI provides the highest sensitivity and specificity for LV thrombus when compared to TTE and TEE9. However, CMRI compared with TTE, is less available, more expensive and less tolerated by the patients10. Treatment with oral anticoagulants in heart failure patients with previous myocardial infarction and mural LV thrombus has been recommended especially in patients who have experienced a previous embolic event11,12. Elective surgery is reserved for patients who have concomitant indication for myocardial revascularization and or aneurysmectomy, especially if associated to heart failure13,14.
3. Conclusions In our case, contrast echocardiography has been useful to confirm the diagnosis of giant LV thrombus and to exclude impending LV wall rupture. Surgical option of aneurysmectomy in addition with thrombus excision should be considered in clinical practice especially when anticoagulant therapy is ineffective or not indicated due to high hemorrhagic risk.
39
Conflict of interest The authors have no conflicts of interest to disclose. References 1. Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F. Left ventricular aneurysm: a new surgical approach. Thorac Cardiovasc Surg 1989;37(1): 11–9. 2. Chiarella F, Santoro E, Domenicucci S, Maggioni A, Vecchio C. Predischarge two-dimensional echocardiographic evaluation of left ventricular thrombosis after acute myocardial infarction in the GISSI-3 study. Am J Cardiol 1998;81(7):822–7. 3. Sharma ND, McCullough PA, Philbin EF, Weaver WD. Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction. Chest 2000;117(2):314–20. 4. Nayak D, Aronow WS, Sukhija R, McClung JA, Monsen CE, Belkin RN. Comparison of frequency of left ventricular thrombi in patients with anterior wall versus non-anterior wall acute myocardial infarction treated with antithrombotic and antiplatelet therapy with or without coronary revascularization. Am J Cardiol 2004;93(12):1529–30. 5. Domenicucci S, Chiarella F, Bellotti P, Bellone P, Lupi G, Vecchio C. Longterm prospective assessment of left ventricular thrombus in anterior wall acute myocardial infarction and implications for a rational approach to embolic risk. Am J Cardiol 1999;83(4):519–24. 6. Mansencal N, Bordachar P, Chatellier G, Redheuil A, Diebold B, Abergel E. Comparison of accuracy of left ventricular echocardiographic measurements by fundamental imaging versus second harmonic imaging. Am J Cardiol 2003;91(8):1037–9. 7. Thanigaraj S, Schechtman KB, Pe´rez JE. Improved echocardiographic delineation of left ventricular thrombus with the use of intravenous second-generation contrast image enhancement. J Am Soc Echocardiogr 1999;12(12):1022–6. 8. Mansencal N, Nasr IA, Pillie`re R, Farcot JC, Joseph T, Lacombe P, et al. Usefulness of contrast echocardiography for assessment of left ventricular thrombus after acute myocardial infarction. Am J Cardiol 2007;99(12): 1667–70. 9. Srichai MB, Junor C, Rodriguez LL, Stillman AE, Grimm RA, Lieber ML, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J 2006;152(1): 75–84. 10. Mollet NR, Dymarkowski S, Volders W, Wathiong J, Herbots L, Rademakers FE, et al. Visualization of ventricular thrombi with contrast-enhanced magnetic resonance imaging in patients with ischemic heart disease. Circulation 2002;106(23):2873–6. 11. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, et al. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J 2005;26(11):1115–40. 12. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005;112(12):e154–235. 13. Nili M, Deviri E, Jortner R, Strasberg B, Levy MJ. Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases. Ann Thorac Surg 1988;46(4):396–400. 14. Kalkat MS, Dandekar U, Smallpeice C, Parmar J, Satur C, Levine A. Left ventricular aneurysmectomy: tailored scar excision and linear closure. Asian Cardiovasc Thorac Ann 2006;14(3):231–4.
Journal of Cardiovascular Echography 22 (2012) 37–39 www.elsevier.com/locate/jcecho
Case report
Surgical treatment of giant left ventricular apical thrombus diagnosed with contrast echocardiography in patient with previous anterior myocardial infarction Rodolfo Citro *, Antonio Panza, Marco Mirra, Lucia Tedesco, Roberta Giudice, Chiara Paolillo, Roberto Ascoli, Antonio Longobardi, Emanuele De Ruberto, Severino Iesu, Giuseppe Di Benedetto ‘‘Heart’’ Department, ‘‘San Giovanni di Dio e Ruggi d’Aragona’’ University Hospital, Salerno, Italy Received 7 December 2011; accepted 9 January 2012; available online 4 February 2012
Abstract Introduction: We report a case of a 66-year-old man with previous anterior ST-elevated myocardial infarction, treated with primary percutaneous coronary intervention and insertion of drug eluting stent on the left anterior descending coronary artery, and left ventricular (LV) apical aneurysm due to no-reflow. After 2 months follow-up contrast echocardiography allowed to detect giant apical LV thrombosis and to exclude impending LV wall rupture. Anticoagulant oral therapy failed to dissolve the thrombus. Aneurismectomy with left ventricular remodeling and excision of the thrombus was performed successfully and the patient was discharged in good condition. Conclusions: Contrast echocardiography was fundamental in diagnosis of LV thrombus excluding an impending LV wall rupture and to guide treatment. # 2012 Societa` Italiana di Ecografia Cardiovascolare. Published by Elsevier Srl. All rights reserved. Key words: Myocardial infarction; Contrast echocardiography; Intraventricular thrombus; Left ventricular aneurism; Cardiac surgery.
Riassunto: Escissione chirurgica di trombo gigante in apice del ventricolo sinistro diagnosticato con ecocardiografica con mezzo di contrasto in paziente con pregresso infarto miocardico anteriore Introduzione: Riportiamo il caso di un paziente di 66 anni con precedente infarto miocardico anteriore con sopraslivellamento del tratto ST, trattato con angioplastica primaria e impianto di stent medicato su arteria discendente anteriore della coronaria sinistra, e aneurisma dell’apice del ventricolo sinistro secondario ad assenza di riperfusione adeguata (no-reflow). Al controllo dopo 2 mesi, l’ecocardiografia con mezzo di contrasto ha permesso di riconoscere un trombo murale di notevoli dimensioni localizzato in corrispondenza di aneurisma dell’apice del ventricolo sinistro e, contestualmente, di escludere una rottura di parete miocardica. Il trombo e` stato resistente alla terapia anticoagulante. Il paziente e` stato sottoposto a intervento chirurgico di aneurismectomia con trombectomia piu` plastica del ventricolo sinistro, e dimesso dopo 7 giorni senza complicanze e in buone condizioni generali. Conclusioni: L’ecocardiografia con mezzo di contrasto e` stata fondamentale nella diagnosi di trombosi ventricolare sinistra, escludendo una possibile rottura di parete, e nel guidare il trattamento. # 2012 Societa` Italiana di Ecografia Cardiovascolare. Pubblicato da Elsevier Srl. Tutti i diritti riservati. Parole chiave: Infarto del miocardio; Ecocardiografia con mezzo di contrasto; Trombo intraventricolare; Aneurisma del ventricolo sinistro; Chirurgia del cuore.
1. Case report We report a case of a 66-year-old man admitted to our Department with chest pain onset 5 hours before due to anterior
* Corresponding author. E-mail address: [email protected] (R. Citro).
ST-elevated myocardial infarction. Patient underwent primary percutaneous coronary intervention (PCI) and implantation of a drug eluting stent (DES) in the middle left anterior descending coronary artery (LAD). After the procedure TIMI flow 1 on LAD was detected (no-reflow). ST-segment elevation persisted in the anterior precordial leads. Transthoracic echocardiography (TTE) showed left ventricular (LV) enlargement and reduced ejection fraction (EF; 45%). Wall motion analysis
2211-4122/$ – see front matter # 2012 Societa` Italiana di Ecografia Cardiovascolare. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.jcecho.2012.01.002
[(Fig._1)TD$IG] 38
R. Citro et al. / Journal of Cardiovascular Echography 22 (2012) 37–39
Fig. 1. a, b. Transthoracic echocardiography, apical four chambers view. a) Mural thrombus in left ventricular aneurism can be appreciated. b) Left ventricular opacification after SonoVue injection. Large thrombus appears as a contrast defect in apex.
[(Fig._2)TD$IG]
revealed akinesis of the apex and the mid segments of interventricular septum and ipokinesia of the mid anterior wall segment with normal contractility of the remaining LV wall. Furthermore, mild pericardial effusion was observed. Patient was discharged after 8 days with beta-blockers, ACE-inhibitor, aspirin, clopidogrel and statin.At 2 months follow-up patient was asymptomatic, ECG was unchanged, TTE showed further enlargement of LV secondary to unfavorable remodeling and aneurismal evolution of the apex with further reduction of LV EF (40%) and no signs of increment of LV filling pressure. Giant apical thrombus (34 mm x 71 mm) adherent to the apex was detected. The TTE was not able to clarify the relationship between the myocardial wall and the giant thrombus (Fig. 1a). Pericardial effusion was unchanged. In order to rule out covered, impending rupture of myocardial wall, cardiac magnetic resonance imaging (CMRI) was proposed. Unfortunately, the patient refused it due to claustrophobia. For this reason, contrast echocardiography by using SonoVue (Bracco Imaging, Italy) as contrast agent was performed with Sequoia 512 (Siemens, Mountain View, California, USA).
Echocardiographic machine was set for LV opacification (Cadence, Contrast Pulse Sequence; second harmonic 1.5 MHz, low mechanical index = 0.3, gain = 16 dB, dynamic range = 50 dB, depth = 12-14 cm, delta = 3, post proc S1/0/1/3 and focus toward apex). After bolus injection with syringe pump of 2 mL of SonoVue (followed by bolus of 5 ml of physiologic solution) an apical thrombus, visualized as a contrast defect in the cavity with no perfusion of microbubbles in the context of mass and into the pericardial space, was appreciated (Fig. 1b). On these grounds oral anticoagulant therapy was started. After 15 days, despite an optimal INR, the thrombus appeared unchanged. Surgical excision of the LVaneurism and thrombus was planned. Cardiopulmonary bypass was established by aortic and single venous cannulation through the right atrium appendage, and the heart was arrested with antegrade cold blood cardioplegia. At inspection no epicardial tearing was appreciated. A 4 cm long left ventriculotomy was performed, 3 cm away and parallel to the distal third of the LAD. After the incision, a 4 x 2 cm friable mass with an irregular surface was detected in the LV apical aneurysm and
Fig. 2. a, b. a) Left ventriculotomy shows a giant apical thrombus with a sucker tip inserted through it. b) thrombus removed.
R. Citro et al. / Journal of Cardiovascular Echography 22 (2012) 37–39
the diagnosis of giant apical thrombus was confirmed (Fig. 2a,b). Patient underwent aneurysmectomy and thrombectomy and ventriculoplasty with a dacron patch insertion according to the Dor technique1. The patient was weaned off cardiopulmonary bypass uneventfully. Postoperative TTE revealed reduced LV volume and a normal LVEF (60%) with mild diastolic dysfunction (abnormal relaxation). Patient was discharged after 7 days in good condition under anticoagulation therapy.
2. Discussion LV thrombi are usually associated with myocardial infarction with an incidence varying between 5% and 28%2. However thrombi can be detected also in other conditions characterized by contraction abnormalities and severe reduction of LV systolic function such as dilated cardiomyopathy, myocarditis, and tako-tsubo cardiomyopathy3. Due to high risk of embolization early detection of ventricular thrombi is fundamental to prevent cerebral or peripheral infarction. During last decade with the increasing practice of primary PCI for STEMI, the incidence of LV thrombi after myocardial infarction is significantly reduced4. However patients with noreflow are at high risk of unfavorable remodeling and aneurismal formation being prone to develop intraventricular thrombi5. In clinical practice TTE by using second harmonic imaging is the most used diagnostic tool to detect LV thrombus with sensitivity and specificity of 95% and 86%, respectively6,7. In case of suboptimal acoustic windows contrast agents in order to better visualize LV cavity can be used. Contrast echocardiography improves visualization of endocardial borders and allows the detection of mural thrombus8. Furthermore, it can be used to unmask artefacts mimicking LV thrombi. However, contrast-enhanced CMRI provides the highest sensitivity and specificity for LV thrombus when compared to TTE and TEE9. However, CMRI compared with TTE, is less available, more expensive and less tolerated by the patients10. Treatment with oral anticoagulants in heart failure patients with previous myocardial infarction and mural LV thrombus has been recommended especially in patients who have experienced a previous embolic event11,12. Elective surgery is reserved for patients who have concomitant indication for myocardial revascularization and or aneurysmectomy, especially if associated to heart failure13,14.
3. Conclusions In our case, contrast echocardiography has been useful to confirm the diagnosis of giant LV thrombus and to exclude impending LV wall rupture. Surgical option of aneurysmectomy in addition with thrombus excision should be considered in clinical practice especially when anticoagulant therapy is ineffective or not indicated due to high hemorrhagic risk.
39
Conflict of interest The authors have no conflicts of interest to disclose. References 1. Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F. Left ventricular aneurysm: a new surgical approach. Thorac Cardiovasc Surg 1989;37(1): 11–9. 2. Chiarella F, Santoro E, Domenicucci S, Maggioni A, Vecchio C. Predischarge two-dimensional echocardiographic evaluation of left ventricular thrombosis after acute myocardial infarction in the GISSI-3 study. Am J Cardiol 1998;81(7):822–7. 3. Sharma ND, McCullough PA, Philbin EF, Weaver WD. Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction. Chest 2000;117(2):314–20. 4. Nayak D, Aronow WS, Sukhija R, McClung JA, Monsen CE, Belkin RN. Comparison of frequency of left ventricular thrombi in patients with anterior wall versus non-anterior wall acute myocardial infarction treated with antithrombotic and antiplatelet therapy with or without coronary revascularization. Am J Cardiol 2004;93(12):1529–30. 5. Domenicucci S, Chiarella F, Bellotti P, Bellone P, Lupi G, Vecchio C. Longterm prospective assessment of left ventricular thrombus in anterior wall acute myocardial infarction and implications for a rational approach to embolic risk. Am J Cardiol 1999;83(4):519–24. 6. Mansencal N, Bordachar P, Chatellier G, Redheuil A, Diebold B, Abergel E. Comparison of accuracy of left ventricular echocardiographic measurements by fundamental imaging versus second harmonic imaging. Am J Cardiol 2003;91(8):1037–9. 7. Thanigaraj S, Schechtman KB, Pe´rez JE. Improved echocardiographic delineation of left ventricular thrombus with the use of intravenous second-generation contrast image enhancement. J Am Soc Echocardiogr 1999;12(12):1022–6. 8. Mansencal N, Nasr IA, Pillie`re R, Farcot JC, Joseph T, Lacombe P, et al. Usefulness of contrast echocardiography for assessment of left ventricular thrombus after acute myocardial infarction. Am J Cardiol 2007;99(12): 1667–70. 9. Srichai MB, Junor C, Rodriguez LL, Stillman AE, Grimm RA, Lieber ML, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J 2006;152(1): 75–84. 10. Mollet NR, Dymarkowski S, Volders W, Wathiong J, Herbots L, Rademakers FE, et al. Visualization of ventricular thrombi with contrast-enhanced magnetic resonance imaging in patients with ischemic heart disease. Circulation 2002;106(23):2873–6. 11. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, et al. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J 2005;26(11):1115–40. 12. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005;112(12):e154–235. 13. Nili M, Deviri E, Jortner R, Strasberg B, Levy MJ. Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases. Ann Thorac Surg 1988;46(4):396–400. 14. Kalkat MS, Dandekar U, Smallpeice C, Parmar J, Satur C, Levine A. Left ventricular aneurysmectomy: tailored scar excision and linear closure. Asian Cardiovasc Thorac Ann 2006;14(3):231–4.