case_images: PMC6358423_01
case_images: Echo (apical 4 chamber) with perflutren contrast showing a 2.4 x 3.8 cm non-perfused mass at the LV apex suggestive of thrombus or infiltrative tumor. LA: left atrium, LV: left ventricle, RV: right ventricle.
case_images: jcvi-27-70-g001.jpg
case_images: PMC6358423_01_jcvi-27-70-g001.jpg
case_images: F1
case_images: There was apical left ventricular thickening concerning for tumor, laminated thrombus or focal hypertrophy (Figure 1, Movie 1).
case_images: (A) Cardiovascular magnetic resonance - Steady State Free Precession (SSFP) still image (apical 2 chamber) showing normal chamber sizes with increased focal apical wall thickness of 22 mm and hypokinesis of this segment. A small pericardial effusion is also seen. (B) First pass perfusion shows hypoperfused apical and lateral endocardium along with a layer of clot lining these segments. (C) Three-chamber late gadolinium enhancement shows fibrosis in the apex in the endocardium extending to the mid myocardium in the shape of a cap. The laminated hypointense clot (arrowhead) produces a "double V" sign when contrasted with the underlying hyperintense fibrosis (asterisk). (D) Three-chamber early gadolinium enhancement with long TI of 600 ms shows dark hypointense thrombus at the apex distinct from the underlying scarred myocardium. LA: left atrium, LV: left ventricle, RV: right ventricle.
case_images: jcvi-27-70-g002.jpg
case_images: PMC6358423_01_jcvi-27-70-g002.jpg
case_images: F2
case_images: Figure 2, Movie 2, 3) showed increased focal apical wall thickness of 22 mm with hypokinesis of this segment (Figure 2A). First pass perfusion revealed hypoperfused apical and lateral endocardium with a layer of superimposed clot (Figure 2B). Late gadolinium enhancement images showed hyperintense apical fibrosis extending from the endocardium to mid myocardium, covered by a cap where laminated clot was present producing a "double V" sign (Figure 2C). This was also confirmed on the 3-chamber early gadolinium enhancement image with long TI of 600 ms that showed apical thrombus distinct from the underlying myocardium (Figure 2D).