January's issue of the AJR has an article by Mohrs et al, where they found that contrast-enhanced CMR did not do as well as expected in the diagnosis of left atrial appendage thrombi as compared to trans-esophageal echocardiography. This conclusion is a little different from a couple of earlier articles, where the technique was found to be as good, if not better.
Though this may be true, contrast-enhanced CMR is still better than trans-thoracic echo. In many countries (India for one), where TEE expertise is limited and is considered an invasive procedure, it may be still be worth-while performing a non-invasive contrast-enhanced study if a trans-thoracic echo is negative or equivocal in a setting with an LA appendage thrombus is suspected.
Having said that, it is possible that gated contrast-enhanced CT may do well. The problem of spatial resolution that Mohrs et al encountered will no longer be an issue and we already know from our experience with pulmonary thrombo-embolism, how good contrast-enhanced CT can be for thrombus detection.
This is a 72-years old man, post-CABG, with atrial fibrillation, who came for a cardiac CT for graft patency. His two venous grafts were patent (Fig. 1). He had mitral and aortic valvular replacement done and the replaced valves were also well seen (Figs. 2, 3). He also had a thrombus in the left atrial appendage (Fig. 4), which was not suspected clinically, but was then re-evaluated and "confirmed" with an echo.
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