Mural Thrombi


Article Author:
Davinder Singh
Hajira Basit
Ahmad Malik


Article Editor:
Kunal Mahajan


Editors In Chief:
Stacy Mandras


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/4/2019 5:50:38 PM

Introduction

Mural thrombi are thrombi that attach to the wall of a blood vessel and cardiac chamber. Mural thrombus occurrence in a normal or minimally atherosclerotic vessel is a rare entity in the absence of a hypercoagulative state or inflammatory, infectious, or familial aortic ailments. Mural thrombi can be seen in large vessels such as the heart and aorta and can restrict blood flow. They are mostly located in the descending aorta, and less commonly, in the aortic arch or the abdominal aorta. Mural thrombi can invade any cardiac chamber. Left ventricular thrombus is a frequent complication of acute myocardial infarction, mostly with the involvement of cardiac apex. This thrombus can separate from the ventricle and travel through arteries, blocking any blood vessels.[1]

Etiology

Virchow's triad describes the pathogenesis of thrombus formation. Endothelial injury initiates the process. It is induced by trauma to the endothelium of blood vessels. Abnormal laminar flow induced by turbulence in arteries propagates the process. Valvulitis or an aneurysm induces it. Then hypercoagulability further enhances the thrombosis. Leukemia or coagulation disorders induce hypercoagulability. These 3 factors create a cascade of events leading to the propagation of thrombus that ultimately occludes the vessels and produces complications.[2]

Epidemiology

Before the lytic and urgent interventional era, left ventricular thrombus occurred in 25% to 40% of patients after a first anteroapical myocardial infarction. With the advent of acute reperfusion strategies, there has been a decline in prevalence. The major risk of left ventricular thrombus is subsequent embolization with stroke or major organ loss. Historically, the likelihood of embolic events was greatest in the first 2 weeks after the acute event and tapered off over the ensuing 6 weeks. After this time, there was presumed endothelization of the thrombus with a reduction in its embolic potential. Now, with the use of thrombolytics and anticoagulants, the incidence of thrombi has diminished but not to a great extent.

Pathophysiology

Thrombus formation starts in response to injury, activating the hemostatic process. Platelets are activated by exposure of collagen or tissue factor. This causes a further cascade of platelet activation with release of cytokines, ultimately causing thrombus formation. A number of cardiac conditions pose an increased risk to thrombus formation. These include atrial fibrillation, heart valve replacement, deep venous thrombosis, acute myocardial infarction, and genetic coagulation disorder. The whole process is regulated by thermoregulation. Large thrombus in a vessel can occlude a vessel and can induce ischemia, also termed as mural thrombi, resulting in the death of tissue. Sometimes thrombi are free-floating and can dislodge to the distal vessel. Embolization to the brain can lead to stroke. Embolization to the limb can lead to amputation.

Histopathology

They appear reddish gray, representing bands of fibrin with entrapped white blood cells (WBC) and red blood cells (RBC). Thrombi are classified into 3 major groups depending on the relative amount of platelets and RBC. Three major groups are white thrombi, characterized by a predominance of platelets; red thrombi characterized by a predominance of RBC; and mixed with features of both white and red thrombi. Thrombi may be mobile, a characteristic which has been associated with a higher embolic potential. On occasion, fresh thrombi take on a cystic appearance. This is due to a combination of factors including varying degrees of maturity of the clot and results in acoustic boundaries between relatively fresh and more organized regions.

History and Physical

The mural thrombus may be symptomatic or may be diagnosed as an incidental finding. Symptoms are mainly related to localization of thrombus. It can be incidentally detected lying in walls of the aorta in an asymptomatic patient. Its embolization to brain induces cerebrovascular events, causes mesenteric ischemia in the gut, and causes renal infarction, coronary ischemia in heart, pulmonary infarction, among others. Its presence in the distal part of the vessel can induce ischemia, which can result in limb loss.[3]

Evaluation

Various modalities can help in a diagnosis, but modality of choice for diagnosis of mural thrombi is CT or MRI angiography. These tools are best for determining the location and extent of mural thrombi. These modalities are costly but helpful in prognostication of disease.[4] Transoesophageal echocardiography (TEE) is another, relatively noninvasive option and a good tool for diagnosis. TTE  is an inexpensive, bedside procedure with a low risk of complications. TEE is also helpful in diagnosing left ventricle thrombus and aortic atheroma especially in ascending aorta. Both MRI and CT are more sensitive than TEE in detecting the thrombus in an entire thoracic aorta. Both are usually well tolerated. Other modalities like intravascular ultrasound or optical coherence tomography have opened up a new era of defining thrombi.

Treatment / Management

Treatment of thrombi could reduce the risk of stroke, myocardial infarction, and pulmonary embolism. There are no standardized guidelines for treatment of mural thrombi. Heparin and warfarin are often used to inhibit the initiation and propagation of existing thrombi. Heparin binds to and activates the enzyme inhibitor antithrombin III, and warfarin inhibits vitamin K epoxide reductase,  both enzymes needed to produce clotting factors. Heparin is a preferred drug for dissolving the clot. If thrombi do not resolve after 2 weeks of heparin therapy, then surgery is an option. Thrombolytic therapy is another option for clot dissolution. It includes streptokinase, urokinase, reteplase, and tenecteplase. These are usually administered intravenously. Surgical candidates include younger patients, those having a low risk of perioperative complications, those in whom conservative treatment is unsuccessful, and those who have a highly mobile thrombus with high embolic risk. Surgical procedure includes thrombectomy, segmental aortic resection, thromboaspiration, and endoluminal stent grafts. No approach is definitively superior. Endoluminal stent grafting is the least invasive option, but it carries the high risk of distal embolization through wire manipulation and stent deployment.[5][6][7][8][5]

Differential Diagnosis

Mural thrombi in the cardiac cavity can mimic a cardiac mass. In the aortic wall, it can appear as mural hematoma or aortic dissection.

Complications

Left ventricular thrombi can embolizes to brain or any other body organ causing fatal events. Aortic mural thrombi , too has high chances of embolisation and higher incidence of limb loss. Mesenteric ischemia, renal infarction, vision loss, myocardial infarction are other rare complications.

Postoperative and Rehabilitation Care

Anticoagulation is an effective means of controlling and preventing the further progression of mural thrombi.

Deterrence and Patient Education

The occurrence of mural thrombi has detrimental effects on morbidity and mortality of cardiac patients. Earlier detection and initiation of timely anticoagulation prevents many complications.

Pearls and Other Issues

Early detection of mural thrombi is of great importance for preventing the complication arising from embolization of thrombi.

Enhancing Healthcare Team Outcomes

The diagnosis and management of mural thrombi is best done with a multidisciplinary team that includes an internist, cardiologist, neurologist, radiologist, vascular surgeon and a team of specialty nurses. It is vital to treat mural thrombi as this can lower the risk of  stroke, myocardial infarction, and pulmonary embolism. There are no standardized guidelines for treatment of mural thrombi. The type of treatment depends on the location of thrombi, patient symptoms, and urgency of the situation. Even after treatment, patients may have to remain on some type of anticoagulation until the cause of the thrombus has been identified and treated.[9][1]

The prognosis for patients with mural thrombi is good but in the presence of emboli, the prognosis is guarded.[10]

 

 


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Mural Thrombi - Questions

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Following a myocardial infarction, what is the most likely cause of flank pain and hematuria?



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What is the most common cause of mural thrombi in the left ventricle?



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A mural thrombus from the left ventricle may embolize to all of the following organs, except which one?



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Mural thrombi are most likely seen in which of the following conditions?



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Following a myocardial infarction, a patient returns for a follow-up visit. He has no complaints. An echocardiogram is done which reveals a left ventricular aneurysm with a 1 cm mass in the apex of the left ventricle. What is the best management?



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Mural Thrombi - References

References

Perini P,Bianchini Massoni C,Azzarone M,Ucci A,Rossi G,Gallitto E,Freyrie A, Significance and Risk Factors for Intraprosthetic Mural Thrombus in Abdominal Aortic Endografts: A Systematic Review and Meta-analysis. Annals of vascular surgery. 2018 Aug 9     [PubMed]
Cicenia M,Fedele F,Petronilli V,De Carlo C,Moscucci F,Schina M,Sciomer S, Hidden in the heart: A peculiar type of left ventricular remodeling after acute myocardial infarction. Echocardiography (Mount Kisco, N.Y.). 2017 Nov     [PubMed]
DeKornfeld GM,Boll J,Ziegler KR,Ratcliff J,Naslund TC,Garrard CL,Valentine RJ,Curci JA, Initial and intermediate-term treatment of the phantom thrombus (primary non-occlusive mural thrombus on normal arteries). Vascular medicine (London, England). 2018 Aug 19     [PubMed]
Eren N,Gungor O,Kocyigit I,Guzel FB,Erken E,Altunoren O,Tatar E,Eroglu E,Senel E,Kaya B,Paydaş S,Onan B,Sahin S,Yilmaz M,Ulu S,Gursu M,Ozkok A,Yildiz A,Kurultak I,Ucar AR,Tanrisev M,Turgutalp K,Turan MN,Huzmeli C,Soypacaci Z,Akdam H,Huddam B,Adibelli Z,Kara E,Inci A,Turkmen E,Tekce H,Dogukan A,Turkmen A, Acute renal infarction in Turkey: a review of 121 cases. International urology and nephrology. 2018 Sep 24     [PubMed]
Desouza N,Sood A,Baciewicz FA,Cardozo S, Traumatic Aortic Mural Thrombus Diagnosed Echocardiographically before Thoracic Endovascular Aortic Repair. Texas Heart Institute journal. 2018 Jun     [PubMed]
Bi Y,Chen H,Zhang W,Ren J,Han X, Treatment of aortic thrombosis with retrievable stent filter and thrombolysis: a case report. BMC cardiovascular disorders. 2019 Mar 5;     [PubMed]
Yang F,Huang PC,Yan LL,Zhang ZD,Fu YF,Xia FF, Catheter Aspiration With Recanalization for Budd-Chiari Syndrome With Inferior Vena Cava Thrombosis. Surgical laparoscopy, endoscopy     [PubMed]
Yagyu T,Naito M,Kumada M,Nakagawa T, Aortic Mural Thrombus in the Non-atherosclerotic Aorta of Patients with Multiple Hypercoagulable Factors. Internal medicine (Tokyo, Japan). 2019 Feb 1;     [PubMed]
Arima T,Muroya K,Kawamoto K,Koba Y,Omura T, Aortic Thrombosis in a Patient With Malignant Disease: A Literature Review and Case Presentation. Vascular and endovascular surgery. 2019 Feb;     [PubMed]
Meyermann K,Trani J,Caputo FJ,Lombardi JV, Descending thoracic aortic mural thrombus presentation and treatment strategies. Journal of vascular surgery. 2017 Sep;     [PubMed]

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