Real-Time Three-Dimensional Echocardiography With Real-Time Volume Rendering in Assessment of Left Ventricular Apical Thrombi
A 36-year-old man with dilated cardiomyopathy was admitted for worsening congestive heart failure. A 2D echocardiogram showed enlargement of the left chambers with global left ventricular hypokinesis; ejection fraction was estimated at 35%. Mild regurgitations of the mitral and tricuspid valves were noted, and the pulmonary artery pressure was estimated at 43 to 48 mm Hg. An echo-dense mass, most consistent with a thrombus, was seen at the apex of the left ventricle. Visualization was partial in the apical views and full in the subcostal view. The extent of the mass and its point of attachment were not visualized (Movie I). A real-time 3D echocardiogram (RT-3D) with real-time volume rendering (RTVR) (Figure) showed a large (2×2 cm) mobile and pedunculated thrombus attached to the left ventricular apex.
RT-3D and RTVR provide multiple simultaneous views of the left ventricle, with excellent structural detail in the near field (apex) (Movie II). RT-3D uses a matrix array probe with 512 active elements, 256 channels with which to send, and 256 channels that receive information. A 16:1 receive mode parallel processing is used to obtain a pyramidal shaped volume containing 4096 scan lines of information in real time. Simultaneous orthogonal plane images (4-chamber and inverted 2-chamber views) with short-axis slices parallel to the face of the transducer (C scans) are obtained for visualization of the left ventricle from multiple vantage points. Because most left ventricular thrombi are present at the apex, the maximum resolution of RT-3D in the near field is advantageous in providing high-quality apical images. RTVR depicts anatomic detail, and by steering the imaging plane, multiple views of the left ventricular thrombus can be obtained from a single acquisition. The present case illustrates the use of RT-3D with RTVR in detection of left ventricular thrombi. RT-3D with RTVR provided comprehensive information about the size, shape, extent, and point of attachment of the thrombus. RT-3D with RTVR is a potentially attractive technique in diagnosis of left ventricular apical thrombi.
Movies I and II are available in an online-only Data Supplement at http://www.circulationaha.org.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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