Contrast echocardiography for assessment of left ventricular thrombi

The diagnosis of intracardiac thrombi remains clinically relevant, with associated risks of systemic embolization and implications for antithrombotic management. Intravenously injected ultrasound contrast agents, composed of microbubbles smaller than red blood cells, have become established essential adjunctive tools for performance of state-of-the-art echocardiography, providing important information on cardiac structure and function. Despite advances in other imaging modalities, echocardiography remains the initial tool for diagnosis and risk stratification in patients predisposed to developing cardiac thrombi. Ultrasound contrast agents are approved for left ventricular (LV) opacification and endocardial border definition. Additionally, the use of contrast echocardiography facilitates LV thrombus detection by providing contrast opacification within the cardiac chambers to clearly show the "filling defect" of an intracardiac thrombus. Furthermore, contrast perfusion echocardiography can provide an assessment of the tissue characteristics of LV masses suspicious for intracardiac thrombi and, by differentiating an avascular thrombus from a tumor, results in improved diagnostic performance of echocardiography. This article presents a clinical vignette highlighting the sound judgment of using contrast echocardiography to aid in the diagnosis of LV thrombi and will review recent advances in imaging modalities for intracardiac thrombus detection.