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Thrombosis and Embolism from Cardiac Chambers and Infected Valves

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Thrombosis and Embolism from Cardiac Chambers and Infected Valves View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector 768 lACC Vol g, No 6 December 1986.76B-87B Thrombosis and Embolism From Cardiac Chambers and Infected Valves PHILIP C. ADAMS, BA, MRCP,* MARC COHEN, MD, FACC,* JAMES H. CHESEBRO, MD, FACC,t VALENTIN FUSTER, MD, FACC* New York. New York and Rochester, Minnesota In a number of cardiac conditions (acute myocardial orrhage is high, and the efficacy of conventional anti• infarction, chronic left ventricular aneurysm, dilated coagulants unclear; thus, anticoagulation should not be cardiomyopathy, infective endocarditis and atrial fi• instituted for the cardiac condition as such. However, brillation in the absence of valvular disease), the risk of in prosthetic valve endocarditis, the risk of embolism embolism gives cause for concern. Although anticoag• seems to be very high, and anticoagulant therapy should ulation with warfarin (Coumadin)-derivatives has been be continued, but with great care because there is a shown to be effective in some of these situations, there substantial risk of cerebral hemorrhage. is no evidence regarding the role of antiplatelet agents. Atrial fibrillation in patients with valvular heart dis• The common factor in the thromboembolic potential ease is dealt with in a previous review. Patients with of acute myocardial infarction, chronic left ventricular nonvalvular atrial fibrillation are at varying risk of em• aneurysm and dilated cardiomyopathy is mural throm· bolism, depending on the etiology of the arrhythmia; bus. This can be detected by two-dimensional echocardi· trials of antithrombotic therapy are needed for the var• ography and indium-Ill platelet scintigraphy. Although ious subsets of patients. In most elderly patients, the of value in elucidating the natural history of mural etiology is not known, and their stroke risk is high. The thrombus, in most cases, management is not substan• risk of embolism in younger patients with idiopathic tially aided by these investigations. atrial fibrillation is so low as to make any antithrombotic In patients with extensive myocardial infarction, par• therapy unnecessary. Patients with atrial fibrillation due ticularly anterior infarction, moderate intensity anti• to hypertrophic cardiomyopathy are at a high risk of coagulation started soon after hospital admission reduces embolism, while for patients with atrial fibrillation due the rate of embolism. After 8 to 12 weeks, embolic risk to ischemic heart disease, the risk is uncertain. Anti• is low so that anticoagulants can usually be discontinued. coagulation is appropriate in some patients around the Patients with chronic left ventricular aneurysm have a time ofdirect current cardioversion. In addition, in those low incidence ofembolism; anticoagulation is, therefore, conditions that would of themselves merit long-term an· inappropriate. Dilated cardiomyopathy is associated with ticoagulation, this should be continued after cardio• a high risk of embolism; moderate intensity anticoagu• version. lation may be advisable in many such cases. Little in• For each patient, the potential benefits of anticoag• formation is available regarding the incidence of throm• ulation have to be carefully balanced against the risks boembolism or the role of antithrombotic therapy in the of bleeding. The intensity of anticoagulant therapy ap• patient with a diffusely dilated left ventricle due to isch• plied should be matched to the patient's clinical condi• emic heart disease. tion. In native valve infective endocarditis, the risk of hem- (J Am Coil CardioI1986;8:76B-87B) In this presentation, we will discuss intracavitary thrombosis diomyopathy. infective endocarditis and atrial fibrillation. and consequent embolism in patients with acute myocardial Embolism makes an important contribution to the morbidity infarction, chronic left ventricular aneurysm, dilated car- and mortality associated with each of these conditions, but there is considerable controversy regarding their optimal antithrombotic management because few large randomized From the *Division of Cardiology, Department of Medlcme, Mount Sinai School of Medicine of the City University of New York, New York, New York and the tDivision of Cardiology, Mayo Clinic, Rochester, Address for reprints: Valentm Fuster, MD, DivisIOn of Cardiology, Minnesota, Dr. Adams is a recipient of a BritJsh-American Research Fel• Mount Sinai Medical Center, One Gustave Levy Place, New York, New lowship of the American Heart Association and British Heart Foundation, York 10029, ©1986 by tbe Amencan College of Cardiology 0735-1097/86/$350 lACC Vol. 8, No 6 ADAMS ET AL 77B December 1986 76B-87B 1NTRACARDIAC THROMBOSIS AND EMBOLISM studies have addressed this issue, Our analysis aims to de• Two-dimensional echocardiography has been applied to scribe the impact of thromboembolism and define the po• the detection of mural thrombi in the three left ventricular tential risks and benefits of anticoagulation in this group of conditions under consideration (18,19) (Fig. 1). Adequate conditions, We offer guidelines for therapy on the basis of images are obtained in most patients (19), and the technique our own clinical practice and the recommendations of the is suitable for repeated observations. Correct interpretation American College of Chest Physicians (ACCP)-National of intracavitary echoes as thrombus is clearly essential. Heart, Lung, and Blood Institute Committee (1), Thrombi are almost always associated with an abnormality of wall motion (12), commonly at the apex. The margins of the thrombus are distinct, with occasionally free motion Mural Thrombi of protruding parts of the mass. The texture of the mass is Intraventricular mural thrombi are common in patients usually different from that of the underlying myocardium. with acute myocardial infarction, chronic left ventricular The mass may vary in appearance in serial examinations. aneurysm and dilated cardiomyopathy, The improvements In some cases, the center of the thrombus is lucent (19,20), in imaging of thrombi by both two-dimensional echocardi• a feature seen shortly before the thrombus becomes unde• ography and scintigraphy with indium-labeled platelets has tectable, and thought to be due to spontaneous lysis (19). led to increased interest in the detection of mural thrombi. Sources of difficulty may include apical trabeculation in with several reviews (2-7) appearing over the last few years, patients with left ventricular hypertrophy, false chordae and Underlying pathology. Two major mechanisms con• tangential imaging of normal left ventricular myocardium tribute to intracavitary thrombus formation in patients with (21). Near field artifact is a particular problem when imaging acute myocardial infarction, chronic left ventricular aneu• from the apex, especially in the presence of increased myo• rysm and dilated cardiomyopathy, namely, abnormalities of cardial echogenicity (20), Despite these problems, studies the endocardium and stasis, In the first 2 days after myo• (18,20,22) of the performance of echocardiography suggest cardial infarction, leukocytic infiltration lifts off the endo• a sensitivity and specificity of 80 to 90% or greater. cardium (8), exposing subendothelial tissue. Consequently, Scintigraphy after the administration of indium-ill-la• the circulating blood is exposed to a thrombogenic surface, beled platelets, unlike two-dimensional echocardiography, and thrombi become common by 4 to 5 days after infarction provides pathophysiologic data by detecting continuing dep• (9), If a left ventricular aneurysm develops, endocardial osition of platelets on the thrombus (18). Images have to abnormalities persist and may be fibroelastic or thrombotic be obtained soon after injection and later after time has (10), The latter is more likely to be the source of emboli, elapsed to allow platelets to accumulate on the thrombus, Endocardial abnormalities may also be seen in patients with typically 3 to 4 days. Only those thrombi actively incor• cardiomyopathy (11). porating platelets are imaged. Because of this, the technique Thrombi developing in patients with myocardial infarc• has a sensitivity of only about 70%, although false positive tion are always adherent to regions of akinesia or dyskinesia studies are unusual (6,23). It is not known whether contin• (12), with stasis of adjacent blood. Stasis of intracavitary uing platelet incorporation into the thrombus, as detected blood within some left ventricular aneurysms can be de• by indium-labeled platelet scintigraphy, is a marker for greater tected by the demonstration of swirling smoke-like echoes embolic potential when compared with the echocardio• by two-dimensional echocardiography (13,14). Stasis in the graphic detection of thrombus that does not take up platelets atria in patients with atrial fibrillation predisposes to throm• actively, bus formation in a similar way. Both two-dimensional echocardiography and indium-la• In patients with myocardial infarction, a third factor, the beled platelet scintigraphy are reliable and efficient tech• systemic reaction to the event, with fever, leukocytosis and niques and have furthered our understanding of the fre• increased plasma concentrations of acute phase proteins, quency and significance of mural thrombi. However, their may also contribute to the tendency to form thrombi (15), value to the clinician in the management of the individual Imaging techniques for the detection of mural throm• patient is not well
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