Role of new echocardiographic technologies
Over the past decade, we have witnessed a development in the armamentarium of echocardiographic technologies capable of providing even more detailed information about LVT. Many of these features allow an integrative approach, as they combine the unique strengths of the single technologic component to achieve unprecedented improvement in our ability to diagnose LVT by TTE. Real-time three-dimensional echocardiography (RT3DE) provides an unlimited (“panoramic”) number of cutting planes in all directions through a single full volume data set (Fig.3). Therefore, cropping and rotating the volumetric data set allow to obtain the perspective that best visualizes a LVT and its attachment to the LV wall. The chance to re-align the tomographic planes obtained from a RT3DE dataset reduces the risk of missing small apical thrombi due to the foreshortening of apical views with two-dimensional TTE.23, 24 However, RT3DE does not allow to differentiate between LVT and myocardium nor to assess the changes in thrombi structure, as it is known that with RT3DE the different shades of blue/brown color give a visual perception of the depth of different structures rather than their texture.
The advent of ultrasound contrast agents, providing the opacification within the cardiac chambers to demonstrate the avascular “filling defect” appearance of an intracardiac LVT, has been critical.25 Indeed, it is now proven that the use of ultrasound contrast agents greatly improves the diagnostic accuracy of TTE from 82% to 92% when compared to CE-CMR.14