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A 68 year old man with a history of anterior myocardial infarction, congestive heart failure, and hypertension was referred for transthoracic echocardiography to evaluate left ventricular function. Tissue harmonic imaging of the apical four chamber view revealed inadequate endocardial definition of all myocardial segments, including the apex (below left). Therefore, images were repeated during intravenous octafluoropropane (Optison) injection. A 2 cm diameter protruding thrombus was visualised as a non-enhanced, spherical structure at the left ventricular apex (below right, arrowheads indicate protruding thrombus). This case illustrates the utility of contrast echocardiography to improve detection of apical thrombus in patients who have inadequate images from routine echocardiographic examination.
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