3. Introducción
Trombo intraventricular, representa riesgo potencial de
embolización sistémica y/o ACV
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
4. Introducción
• Complicación secundaria a IAM
y/o cardiomiopatías
• Se asocia principalmente IAM
c/SDST extenso, pared anterior y
compromiso de ADA
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
5. Epidemiología
Últimos 30 años,
incidencia ha
disminuido reperfusión
temprana
Era pre-reperfusión:
30-60% (SCA c/SDST)
Era pos-treperfusión: 8
% (SCA SDST)
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
6. Meta-análisis 2018, 2000
pacientes con SCA c/SDST
• IAM SDST: 6,3%
• IAM SDST pared anterior: 12,2%
• IAM SDST pared anterior + FE < 50%:
19,2%
Bulluck H. et al. 2018. Incidence and predictors of left ventricular thrombus by cardiovascular magnetic resonance in acute ST-segment elevation myocardial infarction
treated by primary percutaneous coronary intervention: a meta-analysis. Journal of cardiovascular Magnetic Resonance
7. Complicaciones
• Riesgo embolización a 5 años:
16%
• Mayoría eventos embólicos ocurren
< 4 meses
• ACV 13%
• Sangrado mayor 13%
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
8. Fisiopatología
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
9. Factores de riesgo
Trombo intraventricular post IAM
• SCA c/SDST pared anterior
• CAG: ADA (> territorio proximal)
• SCA + FE < 30%
• Retraso entre inicio de síntomas y
reperfusión (↑ riesgo desarrollo
aneurisma)
• Estado hiperinflamatorio: PCR +
fibrinógeno
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
10. Riesgo de embolización
Formación trombo se produce < 2
semanas (media 5 días)
Riesgo embólico ↑ entre 1-2 semanas
post IAM
Criterios ecográficos:
• Movilidad del trombo
• Protrusión
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
12. Diagnóstico
ECO TT S29, E98
ECO TT (con contraste) S64%, E99%
• Evaluar función sistólica
• Trastornos motilidad anteroapical
• Presencia de aneurisma
• Presencia de trombos
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
13. ECO TT
Score movilidad pared apical S100% VPN 100%
> 7 puntos (c/cte)
> 5 puntos (s/cte)
Realizar RNM cardíaca
Puntaje Movimiento pared Movimiento endocardio Grosor pared
1 Normal Normal Normal > 30%
2 Hipokinesia Reducido Reducida < 30%
3 Akinesia Ausente Ausente
4 Diskinesia Movimiento hacia fuera Adelgazada
5 Aneurisma Deformidad diastólica Ausente o adelgazada
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
14. Diagnóstico
RNM cardiaca con Gadolinio (realce tardío) S82-88%, E100% (GS)
Permite evaluar presencia de
trombos
Alteraciones estructurales
Tamaño infarto
Imagen avascular, adherida a
región infartada
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
16. Se recomienda realizar estudio imagenológico
2 semanas posterior a IAM
En paciente con ECO TT < 48 horas
de IAM sin trombos + factores de
riesgo
Repetir imagen a las 2 semanas
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
17. Tratamiento
Anticoagulantes orales
• Resolución completa, parcial,
endotelización del trombo
Se debe estimar riesgo/beneficio, de
anticoagulación + DAPT
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
18.
19. A quienes anticoagular?
IAM + trombo en VI
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
20. Con que anticoagular?
AVK vs NOAC
• 1° línea AVK
• Utilizar NOAC (< RAM) a excepción que
existe contra indicación de uso de AVK
• 83% presenta resolución 264 días
Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
21. Camaj A et al. 2022. Left Ventricular Thrombus Following Acute Myocardial Infarction. JACC
22. Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
23. Massussi M. et al. 2021. Left ventricular thrombosis: new perspectives on an old problema. ESC
24.
25. Prevención?
McCarthy C. et al. 2018. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiology
Mechanically, infarct expansion with regional thinning and dilation of the damaged endothelium in the infarct zone begins almost immediately, increases wall stress, and may lead to ventricular aneurysm formation
Blood stasis is
primarily driven by LV dysfunction with a reduced
ejection fraction and/or large apical or anterior LV
akinesis or dyskinesis (ie, aneurysm) and reduced
contractile function facilitating stasis caused by an
abnormal vortex. Indeed, the presence of LV dysfunction and/or large apical or anterior LV akinesis
or dyskinesis has been strongly associated with LV
thrombus formation in the first 7 days after AMI
abnormal flow patterns resulting from regional LV
dysfunction are closely associated with thrombus
formation compared with normal flow patterns
Local tissue injury in combination with the low
shear rate in the infarct zone activates the coagulation
system, leading to the accumulation of fibrin via
cross-linking (common pathway), platelets (intrinsic
pathway), and erythrocytes, which collectively form
the fresh thrombus
Endothelial injury in the setting of AMI triggers an
inflammatory and prothrombotic state (ie, hypercoagulability)
by exposing subendothelial tissue and
collagen to the circulating blood
Larger infarcts,
evidenced by higher levels of cardiac enzymes, have
also been associated with increased rates of LV
thrombus formation compared with patients with
smaller infarcts.35 Baseline C-reactive protein,
fibrinogen, and the neutrophil-lymphocyte ratio are
independent predictors of early LV thrombus formation
after AMI
The
hypercoagulable state following AMI appears to
persist for up to 6 months or longer
Imagen ecodensa sobre endocardio, contigua a anormalidad segmentaria (aquinesia, hipoquinesia, aneurisma)
