Anti-coagulation Not Working Conjoint Scientific Meeting of Echo - - PowerPoint PPT Presentation

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Anti-coagulation Not Working Conjoint Scientific Meeting of Echo - - PowerPoint PPT Presentation

Dec 04, 2023 43 likes •514 views

Anti-coagulation Not Working Conjoint Scientific Meeting of Echo & CMR Chapters 12 October 2019 Dr. Chan Tin Yau Department of Medicine Pamela Youde Nethersole Eastern Hospital F/63 Non-smoker, non-drinker Good Past health

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Anti-coagulation Not Working

Conjoint Scientific Meeting of Echo & CMR Chapters 12 October 2019

  • Dr. Chan Tin Yau

Department of Medicine Pamela Youde Nethersole Eastern Hospital

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  • F/63
  • Non-smoker, non-drinker
  • Good Past health
  • Incidental finding of AF during an admission to

Surgery for abdominal pain

  • No cardiac symptoms
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SLIDE 3
  • Trans-Thoracic Echo

– A mobile echogenic mass (2.1 x 2.8 x 2.5cm) – Attaching IAS in LA – No mitral inflow obstruction

  • LA thrombus
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SLIDE 4
  • Trans-Esophageal Echo

– Solitary mass (3.6 x 2.3cm) – Attached to IAS – No stalk – Clear LAA and RA

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SLIDE 5
  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve

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  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve

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SLIDE 7
  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve

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SLIDE 8
  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve

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SLIDE 9
  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve

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SLIDE 10
  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve

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SLIDE 11
  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve

  • Favour of thrombus
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  • Anti-coagulation started
  • TTE (3 months later) showed similar LA mass

– Longer duration of adequate anti-coagulation

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  • After 1 year of anti-coagulation
  • LA mass did not decrease in size
  • Refer CTSU
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DISCUSSION

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MRI Basics

  • Relative signal intensity in MR

– Proton density – T1 and T2 relaxation times

  • Different tissues different relaxation times

– Different internal biochemical environments

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Imaging modality

  • T1-weighted

– Fat

  • T2-weighted

– Edema – Liquefactive necrosis

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Imaging modality

  • First-pass Perfusion

– Vascularity of cardiac mass

  • Vascular tumors

 signal intensity enhancement

– Heterogeneous enhancement

  • Vascularity variations
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Imaging modality

  • Early Gadolinium Enhancement

– Optimal technique for thrombus – Blood pool and myocardium have intermediate signal intensity

  • Thrombus no contrast uptake
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Imaging modality

  • Late Gadolinium Enhancement

– Detect myocardial infarction

  • Over time contrast wash out
  • Persist in expanded

interstitial space

– Cellular breakdown permit gadolinium intracellular

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THROMBUS VS MYXOMA

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Thrombus

  • Pseudotumour
  • Typically in left atrium

– Atrial fibrillation – Mitral valve disease

  • Severely dysfunctional left ventricles following

myocardial infarction

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Age of thrombus T1-weighted T2-weighted Early Gadolinium Late Gadolinium Acute Intermediate Intermediate

No uptake

Subacute Low High Chronic Low Low

Signal Intensity for Thrombus

Haemoglobin is still in oxygenated state

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Age of thrombus T1-weighted T2-weighted Early Gadolinium Late Gadolinium Acute Intermediate Intermediate

No uptake

Subacute Low High Chronic Low Low

Signal Intensity for Thrombus

Haemoglobin metabolized to methaemoglobin Different paramagnetic effect High water content from lysed RBC

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SLIDE 31

Age of thrombus T1-weighted T2-weighted Early Gadolinium Late Gadolinium Acute Intermediate Intermediate

No uptake

Subacute Low High Chronic Low Low

Signal Intensity for Thrombus

Thrombus water-depleted Cellular debris replaced by fibrous tissue  greater fibrin content

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SLIDE 32

Age of thrombus T1-weighted T2-weighted Early Gadolinium Late Gadolinium Acute Intermediate Intermediate

No uptake

Subacute Low High Chronic Low Low

Signal Intensity for Thrombus

Enables clear differentiation of thrombus

  • Thrombus is avascular
  • Absence contrast uptake
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SLIDE 33

Thrombus Association

  • Prevalence of thrombus

– Worsening left ventricular ejection fraction – Ischemic etiology – Myocardial scarring

  • Additional value to characterise suspected

thrombus in coronary artery disease

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SLIDE 34
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Myxoma

Benign Most common Fourth to seventh decade Solitary, vary in size Interatrial septum Well defined, smooth, lobular or oval Pedunculated

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Myxoma

  • Sporadic occurrence
  • Asymptomatic if small
  • Symptoms

– Mass effect – Embolization – Constitutional symptoms

  • Surgical resection

– 13% recurrence after resection

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Signal Intensity for Myxoma

T1-weighted T2-weighted Myxoma Isointense High Regions of acute haemorrhage Low Low

  • Cine imaging

– Highly mobile – Prolapse through mitral valve

  • Heterogenous contrast enhancement
  • Layer of surface thrombus

– Low signal intensity on late gadolinium

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WHAT IS NOT SO COMMON IN OUR CASE?

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  • From MRI, the mass was not highly mobile
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  • From MRI and Operation record, the mass had wide base
  • Compared with usual pedunculated apperance
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WHAT CAN WE DO BETTER?

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  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve Heterogenous signal

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  • MRI Cardiac

– Mildly lobulated contour (3.3cm x 3.1cm x 2.7cm) in LA, abutting the IAS – Predominantly low signal in T1 & STIR images – No substantial contrast enhancement in early and late gadolinium imaging – No frank adhesion to mitral valve First-pass perfusion imaging to be done

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Anti-coagulation Not Working

Think about other possibilities

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Thank you