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A 39 year old man presented with a right popliteal artery embolism and was successfully treated with open embolectomy. He was a heavy smoker but had no history of thrombosis, peripheral vascular disease, arrhythmias, ischaemic heart disease, or chest pain. He denied any drug use and his total cholesterol was 5.3 mmol/l. The ECG showed inferolateral Q waves and T wave inversion. Transthoracic echocardiography showed infero-apical akinesia and an apical left ventricular mass (upper panel, middle column). Contrast echocardiography using a low power technique showed reduced enhancement in the infero-apical region in keeping with myocardial infarction and no enhancement of the mass (lower panel, middle column). Contrast enhanced cardiac magnetic resonance also demonstrated a lack of uptake in the mass on turbo spin-echo imaging (upper panel, right column), and on delayed imaging with an inversion recovery sequence, hyperenhancement of the infero-apical region was visible, confirming infarction (lower panel, right column). Coronary angiography revealed smooth unobstructed epicardial vessels. Both contrast echocardiography and magnetic resonance techniques suggested the mass was thrombus rather than tumour and the patient received warfarin treatment for six weeks. Repeat echocardiography showed complete resolution of the mass.
The differentiation of intracardiac thrombus from tumour is important and these images demonstrate the ability of these two non-invasive techniques to assess accurately the nature of the mass in this case. The cause of the myocardial infarction was presumed to be a thrombosis on a non-obstructive coronary plaque that subsequently recanalised, though the lack of chest pain and mode of presentation are unusual, particularly in such a young man.