This is a 55-years old man, who had an old anterior wall infarct. His echocardiogram had been done and showed a 15% EF, but with a probable hibernating anteriow wall. He was advised a CABG and he came for a viability study.
The CMR showed non-viable myocardium in the anterior wall, septum and parts of the inferior and lateral walls (red arrows), as seen on the short axis (Fig. 1) and two-chamber (Fig. 2) images, with aneurysmal dilatation of the mid-cavitary and apical regions. A large "filling defect" was seen along the anterior wall (red arrowheads), which represented a large sessile thrombus. This was not seen on the echo and had given an appearance of a normal thickness, hypokinetic anterior wall, suggesting possible viability. It is easy to understand how this may have happened, since the two-chamber cine MRI also did not show contrast differentiation between the thrombus and the myocardium (avi file).
Another way of identifying thrombi is in the first minute after contrast injection, during the study for MVO (microvascular obstruction).
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