To study the incidence of left-ventricular thrombosis after transmural myocardial infarction, we performed serial two-dimensional echocardiography in 70 consecutive patients. Thirty-five patients had inferior-wall infarction: none had a left-ventricular thrombus. The other 35 had anterior-wall infarction: 12 had left-ventricular thrombi. Thrombi were diagnosed an average of five days after the infarction (range, one to 11 days). All patients with left-ventricular thrombi had severe apical-wall-motion abnormalities (akinesis or dyskinesis). Twenty-six of the 35 patients with anterior infarctions had apical akinesis or dyskinesis on echocardiography; left-ventricular thrombi developed in 12 of these 26 (46 per cent). We conclude that patients with severe apical-wall-motion abnormalities during acute transmural anterior myocardial infarction are at high risk for left-ventricular thrombosis. This high-risk group can be identified before the development of left-ventricular thrombi. Patients with inferior infarction or anterior infarction without a severe apical-wall-motion abnormality are at low risk.

We sought to determine whether an association existed between the echocardiographic appearance of left ventricular thrombi and systemic embolization. We reviewed the clinical and echocardiographic characteristics of 60 patients who underwent diagnostic two-dimensional echocardiography for left ventricular thrombi. Sixteen of these 60 patients (27%) had evidence of systemic embolization. Multiple echocardiographic characteristics of left ventricular thrombi were analyzed, including mobility, shape, heterogeneity, echo density, layering, central echo lucency, presence within an aneurysm, and association with low-density swirling echoes. Incidence of embolization was significantly higher in patients with thrombi that were mobile or protruded into the left ventricular cavity (p < .002 and p < .05, respectively). Bayesian analysis indicated that the pretest likelihood for embolization was 27% and increased in the presence of mobility, central echo lucency, and protrusion to 60%, 50%, and 40%, respectively. A stepwise regression indicated that mobility was the first and protrusion the second most helpful echocardiographic characteristic in identifying patients with embolic phenomena. Clinical features were of less help in identifying the risk for embolization of patients with left ventricular thrombi. Nine of 31 patients (29%) with recent myocardial infarction (less than 3 weeks) had emboli in contrast to five of 26 patients (19%) with remote myocardial infarction (greater than 3 weeks) (p = NS). The three patients without infarction had congestive cardiomyopathy and two had emboli.Circulation 70. No. 4. 588-5989 1984. LEFT ventricular mural thrombus is a common postmortem finding in patients with acute myocardial infarction, '-5 remote myocardial infarction, 1-' left ventricular aneurysm,46 and congestive cardiomyopathy.5 7 Clinical or pathologic evidence for embolization from left ventricular thrombus is much less common.'-' Since it appears that the incidence of embolic events can be reduced by therapeutic anticoagulation,j'9 it is important to identify patients with left ventricular thrombi so that therapeutic intervention can be considered.In the past, the diagnosis of left ventricular thrombus was based on contrast ventriculographic results or inferred only after clinical evidence for an embolic

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In rural US communities, emergency department physician-initiated interhospital transfer of STEMI patients for primary or rescue PCI is feasible and was safely executed with achievement of timely reperfusion when performed within coordinated healthcare networks.

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SUMMARY In two-dimensional echocardiographic studies of left ventricular thrombus in patients, an unusual pattern of dynamic left ventricular intracavitary echoes was identified in some hearts with severe apical dysfunction. These intracavitary echoes were noted in the apical region and were distinct from left ventricular thrombi. Certain features of the intracavitary echoes suggested that they were generated by regional stasis of blood. To study this phenomenon, echocardiography was performed in 1I dogs with experimental anteroapical infarction and associated left ventricular thrombus and in six dogs with infarction but no thrombus. The dynamic intracavitary echo pattern suggesting blood stasis was identified in the ischemic apex in dogs of both groups. These echoes had characteristics suggesting a fluid or semifluid state and could be distinguished from thrombi. In real time, the echoes moved in a slow, circular fashion at the apex and lacked well-defined borders; their configuration and acoustic intensity changed over short periods of time, and they could be rapidly altered bv ectopic or mechanical contraction of the heart and by dopamine infusion. Postmortem examination showed that liquid blood produced the echoes.Additional studies demonstrated the echogenicitv of static blood. Echocardiography of dog hearts with KCI-induced mechanical-asystole showed the rapid development of diffuse echogenicity of the intraventricular rontents; in vitro studies confirmed the echogenicity of static blood.These observations indicate that a spectrum of echocardiographic features characterizes ventricular blood under various conditions of flow and with frank thrombosis. The ability of echocardiographv to detect in vivo stasis of blood in the left ventricle and to distinguish this from thrombosis has important clinical and investigational implications.IN 1975, using M-mode echocardiography, Feigenbaum described accumulations of intracavitary echoes next to dyskinetic segments of the left ventricular wall in patients with coronary artery disease.' He thought these echoes were generated by sluggish blood flow in the area of regional ventricular dysfunction. More recently, Sigel et al. demonstrated the echogenicity of static blood in both in vitro experiments and in the totally occluded canine vena cava. In studies of left ventricular thrombus using two-dimensional echocardiography,-4 we noted dynamic intracavitary echoes in the apex of some patients with severe apical wall motion abnormalities; these echoes were distinct from thrombus and had characteristics suggesting that their source was blood stasis. In studies of experimental left ventricular thrombosis in dogs5 we also found that these dynamic-intracavitary echoes were distinct from thrombi.In this report, we present the characteristics of these intracavitary echoes in man and in dogs and the results of animal studies. Materials and Methods DefinitionsThe following terms are defined as they are used in the manuscript: Dy,namic intracavitarv, echoes the pattern of echoes i...