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LV thrombus on echocardiography

An echo-dense mass at the apex over an akinetic or aneurysmal segment. The border is distinct from the myocardium; confirm it in more than one view.

Watch it in the simulator →Practise random cases

Where to look

Apical 4- and 2-chamber views with a reduced depth and the focus at the apex; confirm in at least two views.

Typical wall-motion pattern

Example: Apical infarct with thrombus

Aneurysmal: apical anterior, apical septal, apex (apical cap) · Akinetic: apical inferior, apical lateral · Hypokinetic: mid anterior, mid anteroseptal

EF in this example: 43% (Impaired (36–49%)).

1 Normal2 Hypokinetic3 Akinetic4 Dyskinetic5 Aneurysmal

Ejection fraction

Across 24 simulated cases of this pattern the true EF ranged from 38% to 55% (median 48%, Impaired (36–49%)). Every case in the simulator is different, so practise until your visual estimate lands in the right 5% range.

Teaching points

LV thrombus forms over akinetic/aneurysmal apical segments. Look for a mass with a border distinct from the endocardium, seen in at least two views.
Ventricular ectopics: the premature beat is weak and dyssynchronous and the beat after the pause is stronger. Judge EF and wall motion on normal sinus beats only.
Atrial fibrillation: filling and EF vary from beat to beat. Average at least five beats, or use an index beat (one that follows two similar RR intervals), and avoid beats after a very short RR interval.

Common pitfalls

Near-field clutter, false tendons and apical trabeculations can mimic a thrombus. A true thrombus has a distinct border and sits on an abnormal segment.

Try it now: open the Infarct with LV thrombus example with the segment overlay, then test yourself in Practice where cases are random and graded against the exact answer.