Chest
Volume 77, Issue 4, April 1980, Pages 463-469
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Clinical Investigations
Prevalence of Mural Thrombi and Systemic Embolization with Left Ventricular Aneurysm: Effect of Anticoagulation Therapy

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Fifty-eight consecutive post-myocardial infarction (MI) patients undergoing surgery for left ventricular (LV) aneurysm were studied retrospectively to assess the frequency, characteristics, and complications of mural thrombi found at surgery, and to determine what effect chronic anticoagulation might have had upon the clinical course of these patients. Mural thrombi at surgery were found in 66 percent (38/58). Of these, only 10 (26 percent) were prospectively identified by LV angiography; conversely, LV angiography misidentified the presence of mural thrombi in 10 percent (2/20) who had no thrombus at surgery. Patients with mural thrombi were not different from those without thrombi in terms of time elapsed since their MI (28 ± 7 vs 24 ± 10 mos), LV end-diastolic pressure (LVEDP) (18 2 vs 18 ± 2 mm Hg), ejection fraction (22 ± 1 vs 25 ± 2%), or angiographic scar size (33 ± 2 vs 29 ± 3%). Of 17 patients receiving long-term therapy with warfarin sodium preoperatively for anticoagulation, nine had mural thrombi, whereas eight did not (NS). There were only two patients in the total group (2/58=3 percent) with a preoperative event compatible with systemic arterial embolization—one of these was anticoagulated. Thus, in postmyocardial patients having LV aneurysmectomy; (1) the prevalence of mural thrombus is high but cannot be reliably identified prospectively by LV angiography or predicted by time since their MI, angiographic scar size, ejection fraction, or LVEDP; (2) the occurrence of preoperative systemic arterial embolization is very low; and (3) chronic anticoagulation has no apparent effect on the frequency of preoperative systemic arterial embolization or the prevalence of LV mural thrombus at surgery.

Section snippets

Patient Population

The study population consisted of 58 consecutive patients from September 1971 through December 1976 at the University of Alabama Medical Center undergoing (1) coronary angiography, (2) biplane LV angiography, and (3) resection of postinfarction LV aneurysm. Patients having cardiac catheterization at other hospitals and referred to this institution for surgery were not included in this analysis. Due to the referral nature of this institution, uniformity in clinical management prior to surgery

Clinical and Angiographic Data

Fifty eight patients satisfied the study criteria (Table 1). The group was composed of 50 men and 8 women with an average age of 55 ± 1 years. The mean elapsed time since MI was 26 ± 6 months. Twenty-eight patients, representing 48 percent, had multivessel coronary artery disease representing either two or three-vessel disease. The mean LV end-diastolic pressure was 17 ± 1 mm Hg, while the average ejection fraction was 23 ± 1 percent. The mean size of the abnormally contracting segment was 32

Discussion

The results of this study suggest the following: (1) the prevalence of mural thrombi is high in patients with LV aneurysm; (2) factors such as severity of coronary artery disease, LV function, and size of the abnormally contracting segment do not identify patients at risk to have mural thrombi; (3) biplane LV angiography is neither sensitive nor specific for the detection of mural thrombi; (4) clinically apparent systemic embolization is uncommon and does not appear to be affected by long-term

Acknowledgments

The authors gratefully acknowledge the secretarial assistance of Ms. Dana Murray. Gratitude is expressed to cardiovascular surgeons John W. Kirklin, M.D., Robert B. Karp, M.D., and Albert D. Pacifico, M.D., for the opportunity to include their patients in this study.

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    This research was supported by the National Heart and Lung Institute (Specialized Center of Research for Ischemic Heart Disease) Contract Number 1P17HL17667-04 by Program Project grant HL 11, 310, and by the Clinical Research Unit grant MO-RR000-13 (General Clinical Research Centers Program, Division of Research Resources of the National Institutes of Health).

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    Manuscript received January 26; revision accepted June 21.

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