echocardiographic, and pathologic features. repeated

Calcified left ventricular thrombus causing repeated retinal arterial emboli: clinical, echocardiographic, and pathologic features. J G Cullen, K Korcuska, G Musser, N B Schiller and R D Clark Chest 1981;79;708-710 DOI 10.1378/chest.79.6.708 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/79/6/708

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1981by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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Calcified

Left

Causing

Ventricular

Repeated

visual disturbances. and left monocular ings from physical able. The patient

Thrombus

Retinal

Arterial

Emboli* Clinical,

Echocardiographic, Feafures

Pafhologk James

G. Cul ten,

Gene

Musser,

Ralph

The

D. Clark,

tual

clinical,

echocardiographic,

of

loss

vision

confirmed

logically moved.

Ic diagnosis

W

visual

field

in

left

his

across

the

left

at surgery

consistent The

and

of left

a

leading

to even-

M-mode

and

studies suggested ventride. These a calcffied

calcified

literature ventricular

features

thrombus are with a two-year

defects eye.

when

with

pertinent

pathologic

left ventricular adult man

echocardiographic

mass extending were

R.D.M.S.;

M.D.4

and

calcified a young

transient of

sectional

Korcuska,

B. Schiller,

Nelson

M.D.

of a discrete presented in history

Kathleen

M.D.;

M.D.;f

and

on the thrombi

cross-

a large findings

mass

thrombus

pathowas

re-

echocardiographis reviewed.

e present

the findings in a young, otherwise healthy with repeated retinal arterial embolization in whom a discrete calcified left ventricular thrombus was diagnosed by both M-mode and cross-sectional echocardiograms and was subsequently confirmed at surgery. Although mural thrombi are quite common in patients with coexisting left ventricular disease, no evidence of myocardial abnormality was present in this patient’s history, electrocardiogram, or biplane left ventricular cineangiogram. The case illustrates that M-mode and cross-sectional echocardiogranas are valuable tools in the evaluation of patients with unexplained embolic phenomena. adult

CASE

This 27-year-old physician in 1915, 0From the of Pacific

REPORT

lumber-truck complaining

Division Medical

driver came transient

of

to his vertigo

of Cardiology, Presbyterian Center, San Francisco.

tPresently with Division of Cardiology, Hospital, Madison, Wis. Cardiovascular Division, Department versity of California, San Francisco. Reprint requests: Dr. Clark, Presbyterian 7999, San Francisco 94120

Madison of

Hospital General

Uni-

Medicine, HospItal,

local and

P0

Box

arterial occlusion detected, but the findexamination were otherwise unremarkwas placed on therapy with sodium warfarin (Couinadin), but over the next two years he experienced approximately 20 episodes of transient defects in the visual field, despite therapeutic anticoagulation. In March 1978, after a severe episode of loss of the right upper visual field, he was referred to Pacific Medical Center. The patient denied a history of trauma to the chest, rheumatic fever, cardiac murmur, palpitations, petechiae, intravenous use of drugs, fever, loss of weight, hematuria, focal weakness, and sensory change. The findings from physical examination were normal, except for optic atrophy and left monocular blindness with a focal retinal arterial embolic lesion on the right, which had the appearance of calcium. The electrocardiogram demonstrated a pattern of Wolff-Parkinson-White preexcitation, but was otherwise Left

central

blindness

retinal

were

normal; no arrhythmias were noted during cardiac monitoring. On the chest x-ray film, the cardiac size was normal, but a large irregular area of calcification was noted in the region of the left ventricle. M-mode echocardiographic studies on condensed scan demonstrated a relatively nonmobile, left ventricular echodense mass extending from the level of the chordae tendineae across the left ventricular cavity toward the apex, where the mass appeared contiguous with the interventricular septum (Fig 1 and 2). In addition, presystolic anterior notching of the endocardium of the left ventricular posterior wall consistent with “type-A” Wolff-Parkinson-White preexcitation was seen near the mitral valve (Fig 1). The remainder of the echocardiograns was normal. Cross-section-

al echocardiographic studies confirmed the presence of a left ventricular mass; the apical four-chamber view (Fig 3) and the parasternal long-axis view (Fig 4) demonstrated an irregular, relatively nonmobile echo-dense structure occupying the entire left ventricular apex and extending approximately 5 cm toward the base of the heart to approximately the level of the papillary muscles. The remainder of the cross-sectional metric left

study ventricular

was normal, contraction

with a pattern and no evidence

of symof other

intracardiac lesions. Biplane left ventricular cineangiographic studies showed a large, intracavitary calcified mass in the left ventricular apex contiguous with the interventricular septum. Left ventricular size and contractile pattern were normal, with no mitral regurgitation. Coronary arteriograms were also normal. At surgery a large calcified intracavitary mass was observed, involving the apex, the interventricular septum, the free left ventricular wall, and to a small extent the 1. Condensed M-mode scan root (AO) toward left ventricular apex. Solid arrow indicates abnormal echocardiographic densities extending from just below Ficuax

from

mitral cavity (IVS).

left

aortic

valve across left to interventricular Note ventricular

ventricular

septum motion of posterior wall to these echo-

normal

(LVPW) posterior cardiographic densities. Open arrow indicates presystolic anterior motion of left ventricular posterior wall typical of Wolff-ParkinsonWhite syndrome (type A). LA, Left atrium.

708

CULLEN ET AL

CHEST, 79: 6, JUNE, 1981 Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011 © 1981 American College of Chest Physicians

----

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be useful in the diagnosis of left ventricular masses. Two cases of left ventricular myxoma diagnosed as a discrete mass by M-mode echocardiograms8’9 and an intracavitary metastatic melanoma and an intramural left ventricular hemangioma diagnosed by cross-sectional echocardiogramshl occur in the literature. On the other hand, left ventricular mural thrombus may pose a more difficult problem with respect to echocardiographic diagnosis, primarily because of its often apical

-

1_I

,..

#{149}--..-

,.,A.

-.‘--

.j

L

-.

_----+-

--

-

-

location

.5

FICUBE

appear

2.

Abnormal

echocardiographic interventricular cavity. Normal

with

contiguous left ventricular

within tum, and left ventricular evident.

posterior

wall

densities septum

(Mass)

(1VS) interventricular sep(LVPW) motion are

papillary muscles. The mass was split in its center, with a raw surface of calcium exposed. The mass was completely excised without need for mitral valvular replacement Pathologic examination of the mass demonstrated acellular hyalinized material with calcification, most consistent with a calcified thrombus. No evidence of myxoma was found on careful review and repeated sectioning. In two years of follow-up, the patient has not experienced further embolic

episodes.

DiscussIoN Left ventricular masses, although quite uncommon, are responsible for considerable morbidity and often are undetected until discovered at surgery or autopsy. Pathologically, such masses may be myxomas, primary or metastatic malignant neoplasms, benign tumors, or left ventricular thrombi. Although left ventricular myxomas

are

reported

attention

on

left

cardiographic thrombi

most

ventricular

thrombi

diagnosis. occurring

commonly,19 Reports

as isolated

discrete

we focus and

of

left masses

our echoventricular

their

are

rare.1#{176}

Most frequent are reports of mural thrombi found in association with left ventricular aneurysms or in areas of previous infarction. Echocardiograms have only recently been shown to

and

a left

small

adherent

nature.

Horgan

et

a112 sug-

M-mode echocardiograms on the basis of septal thinning and vague, “dust-like” abnormal echoes near the interventricular septum in a patient with a prior anterior myocardial infarction; however, Ports et al” report that these Mmode echocardiographic findings are nonspecific and were suggestive in only two of eight patients with documented left ventricular thrombi. Cross-sectional echocardiograms in these eight patients, all with previous myocardial infarction and documented left ventricular aneurysms, detected the four large, inhomogeneous left ventricular thrombi but did not identify the four cases of smaller, adherent mural thrombi; these latter cases were not reliably detected by either M-mode or twodimensional echocardiograms. Thus, the cross-sectional echocardiogram appeared to be a more sensitive tool than the conventional echocardiogram; however, even it was unable to detect a large number of left ventricular thrombi. Reeder and colleagues’s reported that two-dimensional echocardiograms correctly diagnosed ten of 13 patients as having left ventricular thrombi in whom surgical or pathologic confirmation was available. Cross-sectional echocardiograms offer several distinct advantages over conventional M-mode echocardiograms in the diagnosis of left ventricular masses. First, suspected intracardiac abnormalities can be more accurately distinguished from nonspecffic or artifactual echoes, both because of the superior spatial orientation provided by the two-dimensional sector and because the cross-sectional echocardiogram allows visualization of the left ventricle from several different windows (parasternal, apical, and subcostal). A questionable abnormality in one view should always be visualized in the same anatomic location from another window before a mass is definitely diagnosed. In addition, crossgested

ventricular

thrombus

on

FIGURE 3. Stop-frame image cal four-chamber view. Mass

of api(MA) is seen in left ventricular (LV) apex. RV, Right ventricle; BA, right atrium; and LA, left atrium.

CHEST, 79: 6, JUNE, 1981

LEFT VENTRICULARTHROMBUSCAUSING RETINAL EMBOLI

Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011 © 1981 American College of Chest Physicians

709

4. Stop-frame image through long axis of left ventricle. Mass (MA) is seen in left ventricular apex. Ant, Anterior; Inf, FIGURE

parastemal

Inferior; S, septum; Sup, superior; PW,

posterior sectional echocardiograms are able to examine parts of the left ventricle that are inaccessible to accurate diagnosis by the M-mode technique. This advantage is particularly applicable to visualization of the left ventricular apex, a common site of thrombi, which is not reliably examined by conventional echocardiograms but

is well

chamber

visualized apical

with

views

of

cardiogram; techniques,

however, with accurate diagnosis

is critically

dependent

receiver mass

and and

on

blood.

on

the

patient

two-chamber two-dimensional

proper

gain

settings

mismatch

detection

is unusual

and

of

a

et al. Left

ventricular

nosis and 63:816-23

review

on

the

ventricular

instruments impedance of an orto that of a recently

in

several

respects.

Only

this

case

absence predispose

is

also

quite

unusual,

as

is

of coexisting myocardial disease to such thrombus formation.

the

11

12

one

other articlebo and recently several abstractsl3l5 have reported the echocardiographic diagnosis of a left ventricular thrombus occurring as a discrete mass, rather than as vague echocardiographic densities. Contrary to reported experience, the left ventricular thrombus in this patient was well identified by conventional M-mode echocardiograms. Clinically, the repeat retinal arterial emboli seen in this patient have not previously been described in association with left ventricular masses. The extensive calcification of the thrombi in

ventricular

case

myxoma:

myxoma: of

the

literature.

echocardiographic Am J Med

diag1977;

13

14

15

J, MacAlpin R, Abbasi A, Ellis N, Eber L. Echocardiographic diagnosis of a mobile, pedunculated tumor in the left ventricular cavity. Am J Cardiol 1975; 36:957-59 Ports TA, Cogan J, Schiller NB, Rapaport E. Echocardiography of left ventricular masses. Circulation 1978; 58:528-38 Horgan JH, O’M Shiel F, Goodman AC. Demonstration of left ventricular thrombus by conventional echocardiography. J Clin Ultrasound 1978; 4:287-88 Reeder CS, Tajik AJ, Seward JB. Detection of left ventricular thrombus with two dimensional echocardiography (abstract). Circulation 1979; 60( suppi 2): 11-19 Mikell FL, Asinger RW, Sharma B, Francis G, Hodges M. Serial evaluation of LV thrombus by two dimensional echocardiography (abstract). Circulation 1979; 80(suppl2): 11-19 Gottdiener JS, Schooley RT, Maron BJ, Fauci AS. Cardiac abnormalities in the hypereosinophilic syndrome (abstract). Circulation 1979; 60( suppl 2) :11-19

would

Midsystolic Valve

1 Young RD. Hunter, WC. Primary myxoma of the left ventricle with embolic occlusion of the abdominal aorta and renal arteries. Arch Pathol Lab Med 1947; 43:86-91 2 Newman HA, Cordell AR, Prichard RW. Intracardiac myxoma: literature review and report of six cases, one successfully treated. Am Surg 1966; 32:219-30 3 Gerbode F, Kerth WJ, Hill JD. Surgical management of tumors of the heart. Surgery 1967; 61:94-100 4 Danta C, Williams DO. Multiple emboli from left ventricular myxoma. Br Heart J 1969; 31:799-802 5 Mandel MM, Strimel WH. Ventricular myxoma associated with cerebral embolism. JAMA 1970; 214:2154-56

DOl ET AL

Left

unexplained

which

REFERENCES

710

JM.

atrium;

10 Levisman

the

echocardiographic

acoustic opposed

Carter

four-

between left

BR,

root;

of successful removal. Ann Surg 1971; 173:131-34 7 Collins HA, Collins IS. Clinical experience with cardiac myxoma. Ann Thorac Surg 1972; 13:450-57 8 Morgan D, Palazola J, Reed W, Bell H, Kindred L, et al. Left heart myxomas. Am J Cardiol 1977; 40:611-14 9 Meller J, Teichholz L, Pichard A, Matta R, Litwak R,

echo-

both echocardiographic of a left ventricular mass

acoustic

The

thrombus by current may require the higher ganized thrombus, as formed clot. Our

the the

6 Wilcox

left

aortic

ventricular MV, mitral valve; and Post, posterior.

wall;

LA,

AO, left

Closure

in Primary

of the

Aortic

Pulmonary

Hypertension* Yoshinori Tetsuro

L.

Doi,

Sugiura,

M.D.;

Echocardiographic mary pulmonary #{176}Fromthe St. Vincent

Richard

and David

M.D.;

examination

Hospital;

Division, and

ical School, Worcester, Reprint requests: Dr. Medicine, suki-city,

Osaka

Osaka,

Spodick,

in

hypertension

Cardiology

Medical

Japan

University

M.D.;

Bishop,

L. H.

a

M.D.,

patient

F.C.C.P.

with

demonstrated

pri-

midsys-

Department of Medicine, of Massachusetts Med-

MA. Doi, 3rd College, 560

DIvision,

Department

2-7 Daigaku-cho,

CHEST, 79:

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6, JUNE,

of

Takat-

1981

Calcified left ventricular thrombus causing repeated retinal arterial emboli: clinical, echocardiographic, and pathologic features. J G Cullen, K Korcuska, G Musser, N B Schiller and R D Clark Chest 1981;79; 708-710 DOI 10.1378/chest.79.6.708 This information is current as of July 13, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/79/6/708 Cited Bys This article has been cited by 1 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/79/6/708#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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