Transthoracic Echocardiogram Can Accurately Assess Left Ventricular Thrombus in Patients Who Receive an LVAD: Comparison with Intraoperative Intraventricular Visualization

Purpose Severe left ventricular (LV) dysfunction often presents with left ventricular thrombi (LVT). Data on patients with LVT who receive a left ventricular assist device (LVAD) are scarce. We aimed to analyze the comparative diagnostic value of a pre-implant transthoracic echocardiogram (TTE) for LVT detection against the intraoperative findings at LVAD implantation. Methods We reviewed patient characteristics, TTE images, trans-esophageal echocardiographic images, intraoperative findings and pathology reports from the Center for Advanced Heart Failure Data Registry from May 2012 to August 2018. 299 patients received their first LVAD in this period, 238 of them had an LVAD implanted with the use of cardiopulmonary bypass (CPB), and 61 underwent operations without the use of CPB. In all patients who had CPB during their operation, the left ventricle was intraoperatively visually explored. We analyzed the results of 233 patients who had complete data sets. Results Preoperative TTE identified LVT in 23 of the 233 patients (9.9%); 15 patients (6.4 %) had LVT confirmed via intraventricular visualization. Most of the LVTs were located in the LV apex. Of the 15 patients with visual LVT confirmation, the preoperative TTEs identified an LVT on all but one case. Thus, preoperative TTEs of LVT had a high sensitivity (93%) and specificity (96%), as well as high positive (61%) and negative predictive values (99.5%). In patients with preoperatively identified LVT, all thrombi were removed during LVAD implantation. As compared to those without, patients with LVT were younger (44 ± 17 vs. 56 ± 13 y, p=0.007) and had a lower prevalence of arterial hypertension (50% vs 92%, p<0.001), hyperlipidemia (38% vs. 74%, p=0.003) and implantable cardioverter-defibrillator (38% vs 74%, p=0.001). Conclusion This is the largest and most complete study to assess TTE accuracy compared with intraoperative findings in LVAD patients. TTE is a reliable method for the assessment of LVT before LVAD implantation. Severe left ventricular (LV) dysfunction often presents with left ventricular thrombi (LVT). Data on patients with LVT who receive a left ventricular assist device (LVAD) are scarce. We aimed to analyze the comparative diagnostic value of a pre-implant transthoracic echocardiogram (TTE) for LVT detection against the intraoperative findings at LVAD implantation. We reviewed patient characteristics, TTE images, trans-esophageal echocardiographic images, intraoperative findings and pathology reports from the Center for Advanced Heart Failure Data Registry from May 2012 to August 2018. 299 patients received their first LVAD in this period, 238 of them had an LVAD implanted with the use of cardiopulmonary bypass (CPB), and 61 underwent operations without the use of CPB. In all patients who had CPB during their operation, the left ventricle was intraoperatively visually explored. We analyzed the results of 233 patients who had complete data sets. Preoperative TTE identified LVT in 23 of the 233 patients (9.9%); 15 patients (6.4 %) had LVT confirmed via intraventricular visualization. Most of the LVTs were located in the LV apex. Of the 15 patients with visual LVT confirmation, the preoperative TTEs identified an LVT on all but one case. Thus, preoperative TTEs of LVT had a high sensitivity (93%) and specificity (96%), as well as high positive (61%) and negative predictive values (99.5%). In patients with preoperatively identified LVT, all thrombi were removed during LVAD implantation. As compared to those without, patients with LVT were younger (44 ± 17 vs. 56 ± 13 y, p=0.007) and had a lower prevalence of arterial hypertension (50% vs 92%, p<0.001), hyperlipidemia (38% vs. 74%, p=0.003) and implantable cardioverter-defibrillator (38% vs 74%, p=0.001). This is the largest and most complete study to assess TTE accuracy compared with intraoperative findings in LVAD patients. TTE is a reliable method for the assessment of LVT before LVAD implantation.