TEE for thrombus in dilated cardiomyopathy
TEE for thrombus in dilated cardiomyopathy
By Holly Posner, MD
Matthew E. Schwinger, MD
Mark H. Goldberger, MD
Stuart D. Katz, MD
Department of Medicine, Division of Cardiology
Montefiore Medical Center and The Albert Einstein College of Medicine
Bronx, NY
Large, pedunculated thrombus in the left atrium is a rare and, if left untreated, potentially life-threatening clinical finding that has previously been described in association with mitral stenosis and atrial fibrillation. In contrast, mural thrombus associated with dilated cardiomyopathy is common and is usually located in the left ventricle where it can be detected with a high degree of accuracy by two-dimensional, transthoracic echocardiography.
We report a case of pedunculated left atrial thrombus diagnosed by transesophageal echocardiography (TEE) in a young woman with idiopathic dilated cardiomyopathy and a structurally normal mitral valve without evidence of atrial fibrillation who was successfully treated with medical therapy. (See example of TEE equipment, p. 130.)
The 20-year-old, black, Jamaican-born college student with a two-year history of dilated cardiomyopathy, presented with a three-month history of cough, progressive dyspnea, anorexia, and weight loss. Medications at the time of admission included furosemide 40 mg QD, digoxin 0.25 mg QD, and captopril 12.5 mg TID. The patient had no known prior history of atrial tachyarrythmias.
Physical examination revealed a thin, young woman in moderate respiratory distress, with bitemporal wasting, as well as these vital signs:
• Heart rate was 110 beats per minute and regular.
• Respiratory rate was 28 per minute.
• Blood pressure was 90/60 mmHg.
Significant findings included 15 cm of jugular venous distention and hepatojugular reflux. Lung auscultation revealed rales over the lower third of each field. On repeated cardiac exams, the S1 was soft and of constant intensity. An S3 gallop was present; there were no murmurs. No hepatomegaly or peripheral edema were present. Peripheral pulses were normal. Twelve-lead electrocardiogram revealed sinus tachycardia and left ventricular hypertrophy.
Radionuclide angiography showed a dilated left ventricle with global hypokinesis and a resting left ventricular ejection fraction of 17%. Cardiac catheterization revealed normal coronary arteries, elevated cardiac filling pressures, and reduced resting cardiac output. Endomyocardial biopsy revealed moderate to severe myocellular hypertrophy and moderate interstitial fibrosis without evidence of active myocarditis. Tests for collagen vascular disease, Lyme disease, carnitine deficiency, and HIV infection were all negative. Blood coagulation studies were normal.
Two-dimensional, transthoracic echocardiography showed left atrial and left ventricular enlargement with severe diffuse hypokinesis consistent with dilated cardiomyopathy (LVEDD 6.4 cm, LVESD 5.7 cm, LA size 4.4 cm). The mitral valve was morphologically normal with mild regurgitation detected by Doppler ultrasonography. Additionally, in the left atrium, an anterior 1.2 cm round, sessile mass was identified. Of note, transthoracic two-dimensional echocardiography, performed three months earlier at another institution, had revealed no intracardiac masses.
TEE performed three days later confirmed four-chamber enlargement. The left atrial mass, previously described as sessile, was now seen to be highly mobile, 1.8 x 1.5 cm in dimension, and attached to the interatrial septum by a narrow 1-2 mm stalk. The interatrial septum was normal. The mass did not obstruct left atrial inflow or outflow. A second mass, 1.4 cm in greatest length, was adherent to the right atrial free wall. Spontaneous echo contrast was seen in the left atrium, right atrium, and left ventricle.
[Editor’s note: Reprinted with permission from the CHFNet Web site — www.webaxis.com/chfnet — where the echocardiograms can be viewed. Also see www.asahq.org/Practice/TEE/TEE.html for the American Society of Anesthesiolgists’ Practice Guidelines for Perioperative Transesophageal Echocardiography.
For information on the V5105B, contact Acuson Corp. at (800) 498-7948. Several other companies manufacture similar devices including Hewlett Packard, Toshiba, General Electric, and Siemens.]
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