Diagnostic Utility of a Deliberately Obtained Oblique Apical Echocardiographic View for Detection of Left Ventricular Apical Thrombus Following Acute Anterior Myocardial Infarction: A Case Report

Abstract

Aim: To highlight the diagnostic utility of deliberate transducer manipulation and acquisition of an alternative oblique apical echocardiographic view when conventional apical imaging is inconclusive for suspected left ventricular (LV) apical thrombus. Background: Left ventricular apical thrombus is a recognised complication of extensive anterior myocardial infarction, particularly in the presence of severe apical akinesia and reduced LV systolic function. Although transthoracic echocardiography is routinely used for its detection, visualisation may occasionally be limited when a thrombus is closely apposed to infarcted myocardium and has similar echogenicity. Case: A diabetic and hypertensive male presented to the emergency department within approximately two hours of acute-onset chest pain associated with profuse sweating and hypotension. Electrocardiography demonstrated ST-segment elevation in leads V2–V6, consistent with an extensive anterior wall myocardial infarction, with reciprocal ST-segment changes in the contralateral leads. Initial transthoracic echocardiography demonstrated extensive regional wall-motion abnormalities with an akinetic LV apex and septum, involving the mid and basal anterior septal segments. LV ejection fraction was approximately 35%. Moderate mitral regurgitation, mild tricuspid regurgitation, an estimated RVSP of approximately 42 mmHg, and minimal circumferential pericardial effusion were present. No ventricular septal rupture was identified on colour Doppler. The patient underwent successful primary percutaneous coronary intervention and was subsequently managed with appropriate medical therapy. During follow-up echocardiography, an echogenic structure was suspected in the LV apex. However, its echogenicity was similar to that of the adjacent myocardium, and the conventional apical four-chamber view did not allow confident characterisation despite standard echocardiographic assessment and colour Doppler evaluation. Cardiac magnetic resonance imaging would ordinarily have been considered for further tissue characterisation. However, the patient had significant anxiety, a history of panic attacks and claustrophobia. In the setting of a recent myocardial infarction, prolonged confinement within the MRI environment was considered difficult to tolerate and potentially undesirable. A deliberately obtained modified oblique apical view through the conventional apical acoustic window provided a different spatial orientation of the LV apex. This manoeuvre substantially improved visualisation and demonstrated a discrete apical thrombus closely apposed to the thin, akinetic apical myocardium. Conclusion: This case emphasises the importance of systematic echocardiographic interrogation of the LV apex and the diagnostic value of obtaining alternative imaging planes when the standard view is inconclusive. Deliberate transducer manipulation and acquisition of a complementary oblique apical view may provide decisive diagnostic information and facilitate timely management, particularly when additional advanced imaging is poorly tolerated or not readily feasible.