Cardiac Magnetic Resonance Imaging Used to Determine a Rare Etiology of a Layered Left Ventricular Apical Thrombus

Abstract

Eosinophilic myocarditis (EM) is a rare disease, often associated with hypereosinophilic syndrome (HES). Historically, the diagnostic gold standard was endomyocardial biopsy (EMB). We present a unique case of a 58-year-old female who presents after a syncopal episode and was found to have a layered left ventricular (LV) thrombus. Using laboratory studies and cardiac magnetic resonance imaging (MRI), we were able to delineate the etiology, avoiding any invasive testing.

Keywords: cardiac magnetic resonance imaging; eosinophilic myocarditis; heart failure with reduced ejection fraction.; idiopathic hypereosinophilic syndrome; left ventricular thrombus.

Figure 1. Transthoracic echocardiogram (apical 4-chamber window).

Severely hypokinetic apex with a left ventricular ejection fraction of 34% and an associated large, dense, and layered apical thrombus (highlighted in the figure).

Figure 2. Cardiac MRI (T2 imaging, 4-chamber view).

T2 weighted image demonstrates areas of hyperintensity in the left ventricular apex suggestive of underlying edema and inflammation (red arrow) resulting in complete obliteration of the apex. The overlying area of hypointensity was suspicious for an organized apical thrombus (blue arrow). T1 weighted image demonstrated significant late gadolinium enhancement of the left ventricular apical cavity consistent with a background of myocardial fibrosis and scarring (not depicted).