University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
Eur Heart J Acute Cardiovasc Care. 2023 Oct 25;12(10):703-710. doi: 10.1093/ehjacc/zuad069.
The aim of this study was to investigate predictors of transthoracic echocardiography (TTE)-occult left ventricular (LV) thrombi (LVT) and to propose a clinical model for improved detection of TTE-occult LVT post-ST-elevation myocardial infarction (STEMI). Patients with acute STEMI are at significant risk for developing LVT. However, this complication often (up to 65%) remains undetected by using TTE, referred to as TTE-occult LVT.
In total, 870 STEMI patients underwent TTE and cardiac magnetic resonance (CMR), the reference method for LVT detection, 3 days after infarction. Clinical (body mass index, peak cardiac troponin T) and echocardiographic [ejection fraction, apical wall motion scores (AWMSs)] predictors were analysed. Primary endpoint was the presence of TTE-occult LVT identified by CMR imaging. From the overall cohort, 37 patients (4%) showed an LVT by CMR. Of these thrombi, 25 (68%) were not identified by TTE. Transthoracic echocardiography-occult thrombi did not significantly differ in volume (1.4 vs. 2.74 cm3), diameter (19.0 vs. 23.3 mm), and number of fragments or shape compared with TTE-apparent LVT (all P > 0.05). For predicting these TTE-occult LVT, the 16-segment AWMS (AWMS16Seg) showed highest validity {area under the curve: 0.91 [95% confidence interval (CI): 0.89-0.93]; P < 0.001}, with an association independent of ejection fraction and 17-segment AWMS (AWMS17Seg) [odds ratio: 1.68 (95% CI: 1.43-1.97); P < 0.001] and clinical (body mass index, peak troponin) and angiographic (culprit lesion, post-interventional thrombolysis in myocardial infarction flow) associates of TTE-occult LVT (all P < 0.05). Dichotomization at AWMS16Seg ≥ 8 (n = 260, 30%) allowed for a detection of all TTE-occult LVT (sensitivity: 100%), with a corresponding specificity of 77%.
After acute STEMI, AWMS16Seg served as a simple and very robust predictor of TTE-occult LVT. An AWMS16Seg-based algorithm to identify patients for additional CMR imaging offers great potential to optimize detection of TTE-occult LVT following STEMI.
本研究旨在探讨经胸超声心动图（TTE）隐匿性左心室（LV）血栓（LVT）的预测因素，并提出一种用于提高经胸超声心动图隐匿性 LV 血栓(post-ST-elevation myocardial infarction，STEMI)检测的临床模型。急性 STEMI 患者发生 LVT 的风险显著增加。然而，这种并发症通常（高达 65%）仍未通过 TTE 检测到，称为 TTE 隐匿性 LVT。
共 870 例急性 STEMI 患者在梗死后 3 天接受 TTE 和心脏磁共振（CMR）检查，后者是 LVT 检测的参考方法。分析了临床（体重指数、峰值心脏肌钙蛋白 T）和超声心动图[射血分数、心尖壁运动评分（apical wall motion scores，AWMSs）]预测因素。主要终点是 CMR 成像确定的 TTE 隐匿性 LVT 的存在。在整个队列中，37 例（4%）患者通过 CMR 发现 LVT。这些血栓中有 25 例（68%）未通过 TTE 检出。与 TTE 明显 LVT 相比，TTE 隐匿性血栓的体积（1.4 与 2.74cm3）、直径（19.0 与 23.3mm）和碎片数量或形状无显著差异（均 P > 0.05）。对于预测这些 TTE 隐匿性 LVT，16 节段 AWMS（AWMS16Seg）显示出最高的有效性[曲线下面积：0.91（95%置信区间：0.89-0.93）；P < 0.001]，与射血分数和 17 节段 AWMS（AWMS17Seg）相关，其关联独立于 16 节段 AWMS（odds ratio：1.68（95%置信区间：1.43-1.97）；P < 0.001）和临床（体重指数、峰值肌钙蛋白）和血管造影（罪犯病变、经皮冠状动脉介入治疗后心肌梗死血流）因素（均 P < 0.05）。AWMS16Seg 截断值≥8（n=260，30%）可检测到所有 TTE 隐匿性 LVT（敏感性：100%），相应的特异性为 77%。
急性 STEMI 后，AWMS16Seg 是 TTE 隐匿性 LVT 的简单且非常可靠的预测因子。基于 AWMS16Seg 的算法用于识别需要额外 CMR 成像的患者，为优化 STEMI 后 TTE 隐匿性 LVT 的检测提供了巨大潜力。
