Case

Anatomy

Normal Anatomy

• Apical thinning
• Trabeculations
• False cords/tendons

Imaging

• Seen best in the apical windows (4/2/3) and parasternal short axis
• Imaging greatly improved with contrast

LV Tumour/Endocarditis

will skip, covered recently

LV Thrombus

Features:

• regional wall motion abnormality
• apical location
• distinct margin with jagged edges
• movement separate from the underlying endocardium
• higher echo density as compared with the myocardium

Mimic

False Tendon

• Found in over 50% of LV in autopsy studies
• Unlike trabeculations, they traverse the LV cavity
• Echo free space on both sides
• Taut in diastole, laxe in systole
• Can have broad base attachment
• Can rupture in MI or spont

https://www-sciencedirect-com.proxy1.lib.uwo.ca/science/article/pii/S0894731713001764?via%3Dihub

LV Bands

False Tendon

Muscular Band

Papillary Muscle

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3816159/

https://www.sciencedirect.com/science/article/pii/S2468644120300931

Loefflers

• 3 stages: necrotic (generally cannot see on TTE), thrombotic, and fibrosis (restriction and HF)
• Hallmark is apical obliteration of LV and or RV
• Clues: normal apical wall motion (vs isolated LV thrombus), hypereosinohilia, and valve involvement
• Can mimic isolated LV thrombus and apical HCM

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520398/

https://www-sciencedirect-com.proxy1.lib.uwo.ca/science/article/pii/S0894731720305940?via%3Dihub

Apical HCM

• "Spade-like" LV cavity on diastole
• Can have apical wall motion abnormalities (hypokinesis and aneurysm formation)
• Early dx can be missed (giant negative t waves are a clue)
• Strain may demonstrate apical dyskinesia
• Mid-cavity obliteration and gradient may be present

Text

https://onlinelibrary.wiley.com/doi/epdf/10.1111/echo.14895

https://onlinelibrary-wiley-com.proxy1.lib.uwo.ca/doi/full/10.1111/echo.12900

Fabrys

• Concentric thickness is most common phenotype
• Asymmetric septal hypertrophy, eccentric hypertrophy, and apical hypertrophy also possible
• HCM cohorts, up to 12% diagnosed as Fabrys
• Should be on differential for HCM or unexplained hypertrophy
• Abnormalities in the atria, valves, aorta, and papillary muscles can also be seen

https://www-sciencedirect-com.proxy1.lib.uwo.ca/science/article/pii/S0894731718300415?via%3Dihub#bib20

Fabrys

https://www-sciencedirect-com.proxy1.lib.uwo.ca/science/article/pii/S0894731718300415?via%3Dihub#bib20

• Binary Sign: "hyperechogenic endocardial surface adjacent to a relatively hypoechogenic subendocardial layer"

Non-Compaction

• Multiple criteria exist
• Jenni:
• Thick non-compacted and thin compacted layer (>2:1)
• Flow in the intertrabeculated recess
• Prominent trabecular mesh

https://www-internationaljournalofcardiology-com.proxy1.lib.uwo.ca/article/S0167-5273(14)02384-5/fulltext

https://www-internationaljournalofcardiology-com.proxy1.lib.uwo.ca/article/S0167-5273(14)02384-5/fulltext

Mimic - Hypertrabeculation

• One study showed 18% of athletes have an increased LV trabeculation and 8% fulfilling the conventional criteria for LVNC
• Especially in African/Afro-Carribean athletes
• Longitudinal study needed

Back to the Case

LV Thrombus post Anterior MI

Thank you