Intracardiac Thrombus

Epidemiology

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Etiology

Atrial Thrombus

  • General Comments
    • Left Atrium/Left Atrial Appendage: most atrial thrombi occur in the left atrium/left atrial appendage
    • Right Atrium: thrombi rarely occur in the right atrium
      • When present, they are usually associated with venous thrombus that is extending into the RA from either the inferior vena cava (IVC) or superior vena cava (SVC)
      • Right atrial thombus has been reported in the setting of end-stage liver disease (undergoing orthotopic liver transplantation)
  • Atrial Fibrillation (see Atrial Fibrillation, [[Atrial Fibrillation]])
  • Intracardiac Devices
    • Pacemaker Leads
    • Other Devices
  • Mitral Stenosis (see Mitral Stenosis, [[Mitral Stenosis]])
  • Mitral Valve Replacement
  • Venous Thromboembolism

Ventricular Thrombus

  • General Comments
    • Left Ventricle: left ventricular thrombi usually develop in the left ventricular apex
    • Right Ventricle: thrombi rarely occur in the right ventricle
      • When present, they are usually associated with venous thrombus that is extending into the RA from either the inferior vena cava (IVC) or superior vena cava (SVC)
      • Right ventricular thombus has been reported in the setting of end-stage liver disease (undergoing orthotopic liver transplantation)
  • Acute Myocardial Infarction (see Coronary Artery Disease, [[Coronary Artery Disease]]): due to hypokinesis/akinesis of a given wall
  • Amyloidosis (see Amyloidosis, [[Amyloidosis]])
  • Behcet’s Disease (see Behcet’s Disease, [[Behcets Disease]])
  • Chagas’ Disease (see Chagas’ Disease, [[Chagas Disease]])
  • Dilated Cardiomyopathy/Systolic Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])
  • Left Ventricular Aneurysm (see Left Ventricular Aneurysm, [[Left Ventricular Aneurysm]])
  • Renal Cell Cancer (see Renal Cancer, [[Renal Cancer]]): high risk of intracardiac thrombus when renal cell cancer extends beyond the kidney
  • Intracardiac Devices
    • Pacemaker Leads
    • Other Devices
  • Venous Thromboembolism

Physiology

  • Mechanisms of Intracardiac Thrombus
    • Slowed Intracardiac Blood Flow and Aggregation of Thrombotic Material De Novo within Heart
    • Formation of Thrombus on Intracardiac Devices
    • Formation of Thrombus Elsewhere in the Body with Detection within the Heart While in Transit

Diagnosis

Echocardiogram (see Echocardiogram, [[Echocardiogram]])

  • Spontaneous echocardiographic contrast (“smoke” appearance) is considered a prethrombotic condition and is associated with an increased risk of thromboembolic events [MEDLINE]
  • Trans-Thoracic Echocardiogram: sensitivity: 90%/specificity: 85%
    • Trans-thoracic echocardiogram is considered to have higher sensitivity than trans-esophageal echocardiogram for the detection of left ventricular thrombi, as trans-esophageal echocardiogram incompletely visualizes the apex: the accuracy of trans-thoracic echocardiogram is further increased by using color Doppler and/or intravenous contrast (Definity)
    • Trans-thoracic echocardiogram is considered to have lower sensitivity than trans-esophageal echocardiogram for the detection of left atrial/left atrial appendage thrombi
  • Transesophageal Echocardiogram: may be used in some cases
  • Echocardiographic Features Which Predict an Increased Risk of Embolization
    • Larger Thrombus Size
    • Thrombi Which are Mobile and Protrude into the LV Chamber: particularly in older patients

Cardiac CT (see Cardiac CT)

  • Detection of Left Atrial Appendage Thrombi
    • Sensitivity: 96%
    • Specificity: 100%

Cardiac MRI (see Cardiac MRI)

  • Sensitive

Clinical Manifestations

Gastrointestinal Manifestations

Neurologic Manifestations

  • Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
    • Epidemiology: intracardiac thrombi are found in up to 26% of patients with ischemic CVA [MEDLINE]

Orthopedic Manifestations

Other Manifestations

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Treatment

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References

  • Risk factors for intracardiac thrombus in patients with ischaemic cerebrovascular events. J. Neurol. Neurosurg. Psychiatry75,1421–1425 (2004) [MEDLINE]