Resolution of ventricular thrombus identified by contrast enhanced cardiac MRI.

A 53 year old man was referred for a contrast enhanced cardiovascular magnetic resonance (CMR) scan for assessment of anterior myocardial wall viability. An earlier coronary angiogram had shown a mid left anterior descending artery (LAD) occlusion, and echocardiography had shown mildly reduced global left ventricular function without any other abnormalities. Cine CMR images (steady state free precession sequence) showed a dilated left ventricle (LV) with reduced global systolic function [End-diastolic volume 224 mls (NR 77-195 mls); end-systolic volume 124 mis (NR 19-72 mls); ejection fraction 45%]. There was wall thinning and akinesis of the anteroapical wall and severe hypokinesis of the mid anteroseptal wall. Postgadolinium images (segmented inversion recovery turboFLASH sequence) revealed a prominent LV apical thrombus which measured 1.4 cm at greatest diameter (Figure 1). Using the late gadolinium technique there was extensive (mainly transmural) hyperenhancement (HE) involving the mid and apical septum and the apex. The patient was commenced on warfarin. A second CMR scan repeated after 4 months of warfarin therapy showed complete resolution of the thrombus in the early and late post-gadolinium images (Figures 2 and 3). CMR imaging post-contrast administration is a sensitive tool in the detection of left ventricular thrombi, and overcomes some of the near-field limitations of 2D echocardiography.