39 year old female presents with a history of anti phospholipid syndrome and previous MI presents with sudden onset of LUQ abdominal pain. She states that she has not been taking her warfarin for the past 2 years.
Answer: LV thrombus with splenic thromboembolism
This patient’s presentation of sudden onset of severe abdominal pain with hypodense splenic lesions suggests embolic splenic infarction. The echocardiogram here demonstrates a hypokinetic apical left ventricle. A hyperechoic mobile mass is visible at the apex of the left ventricle, this is most consistent with LV thrombus in this clinical setting.
In patients with suspected embolic effects, a definite cardiac etiology is found by TTE in 10-15% of the cases.1
Common causes of cardiac thrombi include atrial fibrillation, focal wall motion defects, ejection fraction <20%, rheumatic mitral stenosis, cardiac aneurysms, congenital heart disease and prosthetic valves.
Overall, atrial fibrilliation is thought to be the most common source of arterial emboli.2
Current ACC/AHA guidelines recommend an echo in patients presenting with an abrupt occlusion of a major peripheral or visceral artery.1
Accuracy of detecting a cardiac thrombus is extremely user dependent.1
There are several normal structures that may be mistaken for thrombus, including chordae, trabeculae, papillary muscles, and muscle bundles (such as the moderator band).1
When evaluating the heart for thrombus, special attention must be paid to the apical area. A thrombus is usually visualized there, and is generally somewhat more echogenic than the underlying heart tissue.1
The most common manifestations of arterial embolism are strokes and acute lower limb ischemia.2
Cardiac thromboembolic events to the spleen are associated with myocardial infarction, dilated cardiomyopathy and vegetation of infected valves.4
The most common presentation of splenic infarction is left upper quadrant or diffuse abdominal pain and fever.4
Otto, C. (2013). Textbook of clinical echocardiography (5th ed.). Philadelphia, Pa.: Saunders. [Amazon]
Lyaker MR, Tulman DB, Dimitrova GT, Pin RH, Papadimos TJ. Arterial embolism. Int J Crit Illn Inj Sci. 2013;3(1):77-87Pepi M, Evangelista A, Nihoyannopoulos P, et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr. 2010;11(6):461-76. [PDF]