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Echocardiographic detection of left ventricular thrombus in patients undergoing HeartMate II left ventricular assist
Heidi B Schubmehl1, Vakhtang Tchantchaleishvili1, Eugene Storoznsky2
1Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York - USA.
Insights
Preoperative echocardiograms have low accuracy in detecting left ventricular (LV) thrombus before LVAD implantation. This finding suggests a risk of missed thrombus, potentially impacting patient outcomes and surgical planning.
Area of Science:
- Cardiology
- Medical Imaging
- Surgical Procedures
Background:
- Left ventricular (LV) thrombus is a risk factor for pump thrombosis and stroke in patients receiving a left ventricular assist device (LVAD).
- Accurate detection of LV thrombus preoperatively is crucial for safe LVAD implantation and management.
- The diagnostic performance of preoperative echocardiography (transthoracic echocardiogram [TTE] and transesophageal echocardiogram [TEE]) compared to intraoperative findings for LV thrombus has not been previously established.
Purpose of the Study:
- To evaluate the accuracy of preoperative transthoracic echocardiography (TTE) and transesophageal echocardiogram (TEE) in detecting left ventricular (LV) thrombus.
- To compare the sensitivity and specificity of TTE and TEE with intraoperative direct inspection findings for LV thrombus in patients undergoing LVAD implantation.
Main Methods:
- A retrospective review of patients who underwent LVAD placement or exchange between October 2011 and March 2014.
- Analysis of preoperative TTE and TEE data, with validation against direct intraoperative inspection for the presence of LV thrombus.
- Quantitative analysis of the diagnostic performance (sensitivity, specificity) of echocardiographic methods.
Main Results:
- Of 107 LVAD implants in 99 patients, preoperative TTE was available in 86.9% and TEE in 34.6%.
- Preoperative TTE correctly identified LV thrombus in only 2 cases (16.7% sensitivity, 100% specificity), while TEE identified none correctly (0% sensitivity, 93.8% specificity).
- Intraoperative inspection revealed LV thrombus in 14 cases, indicating a significant rate of missed diagnoses by preoperative imaging.
Conclusions:
- Preoperative echocardiography demonstrates low accuracy and sensitivity for detecting left ventricular thrombus, making it unreliable for excluding thrombus presence.
- The low sensitivity of these imaging modalities has significant implications for planning off-pump LVAD exchange procedures, as thrombus may be overlooked.
- Further research is needed to determine the impact of missed LV thrombus on thromboembolic complications and patient survival.
Purpose:
Transthoracic (TTE) and transesophageal echocardiograms (TEE) are considered accurate in detecting the presence of left ventricular (LV) thrombus. A persistent LV thrombus poses risks of pump thrombosis and stroke in LVAD recipients. The relationship between preoperative echocardiography and intraoperative findings at LVAD implantation has not previously been studied.
Methods:
A retrospective review examined all patients undergoing LVAD placement or exchange from October 2011 to March 2014. Preoperative TTE and TEE data were validated with presence of LV thrombus during the direct inspection at the time of LVAD placement, and the findings were analyzed quantitatively.
Results:
Between October 2011 and March 2014, 99 patients underwent a total of 107 LVAD implants. Preoperative TTE was available in 93 (86.9%) cases, while preoperative TEE was available in 37 cases (34.6%). On preoperative TTE, LV thrombus was correctly identified in only two cases, while on preoperative TEE no cases of LV thrombus were identified correctly, and there were 2 false positive reports. Intraoperative inspection revealed presence of LV thrombus in 14 cases. The sensitivity of preoperative TTE was 16.7% and the specificity 100% in detecting LVT, compared to 0% and 93.8%, respectively, for TEE.
Conclusions:
Preoperative echocardiogram offers low accuracy for presence of LV thrombus. Overall, the sensitivity is too low to reliably exclude thrombus. This could have significant implications in planning off-pump LVAD exchange as thrombus could be missed. More data are necessary to determine whether this could have significant effects on thromboembolic complications and survival.
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