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Cardiac Magnetic Resonance for the Evaluation of Suspected Cardiac Thrombus: Conventional and Emerging Techniques
Published on: June 11, 2019
Contrast-enhanced anatomic imaging as compared to contrast-enhanced tissue characterization for detection of left
Jonathan W Weinsaft1, Raymond J Kim, Michael Ross
1Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York 10021, USA. jww2001@med.cornell.edu
Insights
Contrast-enhanced echocardiography significantly improves left ventricular (LV) thrombus detection compared to noncontrast methods. However, delayed-enhancement cardiac magnetic resonance (DE-CMR) identifies additional thrombi, particularly those that are mural or small.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Techniques
Background:
- Left ventricular (LV) thrombus detection is crucial in high-risk patients.
- Contrast echocardiography (echo) relies on anatomic appearance, while delayed-enhancement cardiac magnetic resonance (DE-CMR) uses tissue characteristics.
- The comparative utility of DE-CMR versus contrast echo for LV thrombus is not well-established.
Purpose of the Study:
- To compare contrast-enhanced anatomic imaging with DE-CMR for left ventricular (LV) thrombus detection.
- To evaluate the diagnostic performance of different imaging modalities in high-risk patients.
Main Methods:
- 121 high-risk patients (myocardial infarction or heart failure) underwent multimodality imaging.
- Anatomic imaging included contrast echo, noncontrast echo, and cine-CMR.
- DE-CMR served as the reference standard for tissue characterization.
Main Results:
- DE-CMR identified thrombus in 24 patients.
- Contrast echo significantly improved sensitivity (61% vs. 33%) and accuracy (92% vs. 82%) over noncontrast echo.
- DE-CMR detected thrombi missed by contrast echo, often mural or small apical thrombi.
Conclusions:
- Contrast echo markedly enhances LV thrombus detection in high-risk patients.
- DE-CMR identifies a significant number of thrombi not detected by contrast echo.
- Thrombi unique to DE-CMR are typically mural or small in volume.
Objectives:
This study sought to compare contrast-enhanced anatomic imaging and contrast-enhanced tissue characterization (delayed-enhancement cardiac magnetic resonance [DE-CMR]) for left ventricular (LV) thrombus detection.
Background:
Contrast echocardiography (echo) detects LV thrombus based on anatomic appearance, whereas DE-CMR imaging detects thrombus based on tissue characteristics. Although DE-CMR has been validated as an accurate technique for thrombus, its utility compared with contrast echo is unknown.
Methods:
Multimodality imaging was performed in 121 patients at high risk for thrombus due to myocardial infarction or heart failure. Imaging included 3 anatomic imaging techniques for thrombus detection (contrast echo, noncontrast echo, cine-CMR) and a reference of DE-CMR tissue characterization. LV structural parameters were quantified to identify markers for thrombus and predictors of additive utility of contrast-enhanced thrombus imaging.
Results:
Twenty-four patients had thrombus by DE-CMR. Patients with thrombus had larger infarcts (by DE-CMR), more aneurysms, and lower LV ejection fraction (by CMR and echo) than those without thrombus. Contrast echo nearly doubled sensitivity (61% vs. 33%, p < 0.05) and yielded improved accuracy (92% vs. 82%, p < 0.01) versus noncontrast echo. Patients who derived incremental diagnostic utility from DE-CMR had lower LV ejection fraction versus those in whom noncontrast echo alone accurately assessed thrombus (35 +/- 9% vs. 42 +/- 14%, p < 0.01), with a similar trend for patients who derived incremental benefit from contrast echo (p = 0.08). Contrast echo and cine-CMR closely agreed on the diagnosis of thrombus (kappa = 0.79, p < 0.001). Thrombus prevalence was lower by contrast echo than DE-CMR (p < 0.05). Thrombus detected by DE-CMR but not by contrast echo was more likely to be mural in shape or, when apical, small in volume (p < 0.05).
Conclusions:
Echo contrast in high-risk patients markedly improves detection of LV thrombus, but does not detect a substantial number of thrombi identified by DE-CMR tissue characterization. Thrombi detected by DE-CMR but not by contrast echo are typically mural in shape or small in volume.
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