Since the late 1970s cross sectional echocardiography has been the method of choice for the detection of left ventricular thrombus. This is largely due to the high sensitivity (92–95%) and specificity (86–88%) of echocardiography in the detection of left ventricular thrombus. Cross sectional echocardiography also provides an indication of the size, shape, mobility, location, and point of attachment of a thrombus. Most commonly a thrombus will occur in three clinical settings: recent myocardial infarctions, dilated (congestive) cardiomyopathies, and within chronic left ventricular aneurysms. The echocardiographic appearance of a thrombus can vary from a small to large, immobile, mural thrombus (fig 1) to a protruding mobile thrombus, of various sizes, or in some instances multiple thrombi. The most difficult to diagnose is a small, immobile, apical mural thrombus. A small mural thrombus is often less echo dense, and therefore more difficult to distinguish from underlying myocardium.

The diagnosis of left ventricular thrombus is usually based on an underlying wall motion abnormality, and a cardiac mass that can be distinguished from the surrounding myocardium through different acoustic characteristics. For the purpose of this paper our definition of an apical mural thrombus is a distinct mass of echoes, most commonly seen in the apex throughout the cardiac cycle, and in more than one view.

Mural thrombi are most commonly seen between six and 10 days following an acute myocardial infarction (MI). They occur at the left ventricular apex and are more common following an anterior wall infarction, since anterior MIs involve more of the apex (fig 2). This thrombus usually develops on a dyskinetic or akinetic area or within …