Recurrent Left Ventricular Thrombus After Reverse Remodeling in Ischemic Cardiomyopathy

Figures

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  Figure 1. TTE, CMR, and CAG Findings at the Initial Admission Three-chamber view (A) and high-magnification image of the apical region (B) on TTE. A mobile iso- to hyperechoic mass measuring 10 × 14 mm was detected at the LV apex (red arrows), consistent with an apical thrombus. CAG images of the RCA (C, LAO view) and LCA (D, RAO-cranial view; E, RAO-caudal view). Triple-vessel disease was confirmed, with 99% stenosis (white arrowheads) in the mid-RCA and proximal LAD and total occlusions (white dotted lines) in the mid-LAD and mid-LCx. Four-chamber view on CMR showing subendocardial LGE (yellow arrowheads) in the anterior, anteroseptal, and inferior walls, together with transmural LGE in the apical region (F). CAG = coronary angiography; CMR = cardiac magnetic resonance; LA = left atrium; LAD = left anterior descending artery; LAO = left anterior oblique; LCA = left coronary artery; LCx = left circumflex artery; LGE = late gadolinium enhancement; LV = left ventricle; RAO = right anterior oblique; RCA = right coronary artery; RV = right ventricle; TTE = transthoracic echocardiography.

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  Figure 2. TTE and CAG Findings at 4-Year Follow-Up Four-chamber view (A), 3-chamber view (B), and high-magnification image (C) of the apical region. Despite sustained improvement in LV function (LVEF 53%; EDV 112 mL; ESV 53 mL), recurrence of an apical thrombus measuring 18 × 8 mm was observed (red arrows). CAG images of the RCA (D, LAO view) and LCA (E, RAO-cranial view; F, RAO-caudal view). No evidence of restenosis or newly developed significant stenoses was identified in any of the previously treated coronary vessels. Ao = aorta; EDV = end-diastolic volume; ESV = end-systolic volume; LVEF = left ventricular ejection fraction; RA = right atrium; other abbreviations as in Figure 1.

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  Figure 3. Serial CMR Observation Four-chamber views of the LV in the end-diastolic phase at baseline (A), 3 years (B), and 4 years (C). The sphericity index was defined as the ratio of the LV long-axis length (double-headed red arrow) to the mid-LV short-axis length (double-headed yellow arrow), measured at end-diastole in the 4-chamber view. LV cavity borders are outlined with white dotted lines. Streamline images of 4-dimensional flow MRI at baseline (D), 3 years (E), and 4 years (F). Intra-LV vortices are indicated by white dotted circles. At baseline, no vortex formation was detected in the LV (D). At 3 years, when thrombus recurrence had not yet occurred despite discontinuation of anticoagulation, a large vortex was observed around the basal LV (E). At 4 years, with recurrence of the apical thrombus, only a diminished vortex near the LV outflow tract was detected (F). Abbreviations as in Figure 1.

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  Visual Summary. Recurrent LV Thrombus After Reverse Remodeling in Ischemic Cardiomyopathy: Serial CMR Observations An LV apical thrombus identified at baseline resolved after percutaneous coronary intervention (3-year follow-up) but recurred at 4 years despite clear reverse remodeling. Serial LV sphericity index values (long-axis/short-axis ratio) were 1.81, 1.91, and 2.11. Corresponding 4D flow MRI–derived peak LV apical flow velocities measured 127.5, 141.0, and 47.2 mm/s. Diastolic intraventricular vortex patterns paralleled these hemodynamic changes: a minimal basal vortex with widespread blood stasis at baseline, a large basal-to-mid LV vortex at 3 years (without thrombus recurrence despite withdrawal of anticoagulation), and a markedly reduced vortex near the LV outflow tract at 4 years, coinciding with thrombus recurrence. Intra-LV vortices are indicated by white dotted circles. These serial findings underscore the role of intraventricular flow stasis in recurrent LV thrombus formation, even in the context of structural reverse remodeling. + = presence; − = absence; 4D = 4-dimensional; EDV = end-diastolic volume; ESV = end-systolic volume; LA = left atrium; LVEF = left ventricular…