DK2985_C000 1..28 - AlSharqia Echo Club

Intracavitary Contents 513(A)(B)LARALVRVSAPHENOUS VEIN GRAFT ANEURYSM(C)(D)LIPOMATOUSHYPERTROPHYLARASVCSAPHENOUS VEIN GRAFT ANEURYSMFigure 23.24 Saphenous vein graft aneurysm. Mid-esophageal four-chamber (A, B) and 1018 view (C, D) showing a large circularmass compressing the right atrium (RA) in a patient with previous coronary artery bypass surgery. The saphenous vein graft seems tobe filled with thrombus-like material (LA, left atrium; LV, left ventricle; RV, right ventricle; SVC, superior vena cava). [Adaptedfrom Bansal (22).]VIII. INTRACARDIAC THROMBIA. Left Ventricular ThrombusLeft ventricular thrombi occur in conditions associatedwith stasis of blood and/or regional wall motion abnormalitiessuch as severe left ventricular systolic dysfunction,myocardial infarction, or left ventricular aneurysm. Echocardiographically,it appears as a mass superimposed onand interrupting the normal endocardial contour of a myocardiumwall with severely decreased contractility. Thesethrombi are most often located at the akinetic or dyskineticapex of the LV (see Figs. 8.22 and 8.23). The diagnosis isfurther supported by the presence of associated spontaneousecho contrast (SEC), an indicator of decreasedblood flow velocity, described as dynamic smoke-likeechoes with a characteristic swirling or layering pattern.Larger and more pedunculated thrombi are easier to identifythan sessile thrombi. Thrombi which protrude into theleft ventricular cavity, are freely mobile with an irregularshaggy border and are more likely to embolize. Thedifferential diagnosis of left ventricular thrombus includesbenign and malignant tumors, transducer-related artifactsas well as a variety of normal cardiac structures such asprominent papillary muscles (Fig. 23.27), trabeculationsand false tendons. Filling of the apex of a normal LVwithout regional wall abnormality can be seen in patientswith the hypereosinophilic syndrome, the apical form ofhypertrophic cardiomyopathy or in patients with malignanciesand hypercoagulable state. Primary lymphoma ofthe heart can also fill the apex of the LV.B. Left Atrial ThrombusLeft atrial and LAA thrombi are associated with stasis ofblood in the LA (Figs. 23.4 and 23.5). Predisposingfactors in the formation of LA thrombi include atrial fibrillation,mitral valve disease (especially rheumatic mitralvalve stenosis), left atrial and LAA enlargement and thepresence of prosthetic mitral valves. As for left ventricularthrombus, the presence of SEC favors the diagnosis of athrombus when a mass is found in the LA (Fig. 23.28).Left atrial SEC is seen in .50% of patients with atrialfibrillation and in .80% of those with atrial fibrillationand LAA thrombi (24). Right atrial SEC is seen in only