Clin. Cardiol.
18, 530-534 (1995)
Clinical Pathologic Correlations
This .srt.tion edited by Bruce Wbller;M.D.
Intracardiac Thrombi: Frequency, Location, Etiology, and Complications:
A Morphologic Review-Part I1
HKOCEF. WAI.I.EK, M.D.,*t TODDM.RoHR,P.A.-c.,~ TODDMCLAUCHLIN,
P.A.-C.,t LARRY
ctiAl<l.ES M.ll.,t JULIE FETTERS,
P. TALIEKCIO, M.D.I'
:';CardiovascularPathology Registry, St. Vincent Hospital; tNasser, Smith, & Pinkerton,Cardiology, Inc., Indianapolis,Indiana, USA
Summary: Intracardiac thrombus is a frequent finding at
necropsy. Various cardiac disorders have been associated with
its presence. Part 11 of this 5-part article focuses on atheroscle-
rotic coronary heart disease (myocardial infarction) as an eti-
ology for intracardiacthrombus.
Key words: myocardial infarction, thrombus, cardiac throm-
bus, embolus, right ventricular infarct
Introduction
Intracardiac thrombus may develop a s a consequence of
multiple underlying cardiac disorders. One of the most fre-
quent disorders is acute myocardial infarction (MI). Part I1 of
this 5-part article on intracardiac thrombus will focus on the
frccluency. location. and consequence of intracardiac throm-
bus associated with acute and healed MI.
Secondary Causes of Myocardial Heart Diseases
Atherosclerotic Coronary Heart Disease
Athcroclcrotic coronary atheroderosis ha\ its major
con\equences o n the left ventricle. Ventricular thrombus oc-
Addi-ess for rcprints:
Bruce W;rllcr. M.D.
X333 Naab, Suitc 400,
Iiidiaiiapolis, IN 46260, USA
Received: Decernher IS, 1994
Accepted: March 6, 19%
GRIDER, P.A.-C.,t
curs in patients with acute MI, those in whom acute infarc-
tion is healed, and those who develop ventricular aneurysms
following acute M1.1-29Patients with large infarcts or those
left with severe ventricular dysfunction from extensive sin-
gle or multiple myocardial infarcts have an end stage form of
coronary heart disease referred to as ischemic cardiomyopa-
thy, coronary dilated cardiomyopathy, or end-stage conges-
tive heart failure from coronary heart disease. Each of these
subgroups may develop intracardiac thrombus, which is sub-
ject to emboli.
Acute Myocardial Infarction
Left ventricular thrombus secondary to coronary heart dis-
ease was first emphasized by Garvin" who, in a consecutive
series of77 I patients dying of heart disease, found intracar-
diac (mural) thrombi in 34.4%, with coronary artery disease
the most common etiology (Figs. 14)Left . ventricular throni-
bi generally are found adherent to and adjacent to the zonc of
infarcted ~nyocardium.~~ l 3 During the early stages (hours)of
acute MI, formation of fibrin-platelet thrombi begins at thc
area of infarction. Usually, by the third to fifth day after the
acute event, mural thrombi increase in frequency. especially
in those with fatal acute MLXAbout 10%ofnecropsy patients
with fatal acute myocardial infarcts have left ventricularmitral
thrombus at Day I , but about 60%had rnural thrombus at Day
7 and nearly 90% by 1 month.x Organization of the mural
thrombus may begin as early as 9 days after acute MI and in
some instances is complete by 3 weeks.x It is, however, c o n -
mon to observe new or fresh thrombus or partially organized
thrombus at sites of old (healed) myocardial infarcts.x
The incidence of left ventricular thrombus in patients with
acute, healed, or both myocardial infarcts (without aneurysm)
varies considerably. Review of 17 previously published re-
~ -2270
p o r t ~ of ~ ~ necropsy patients (Table I) in this category
from 1926to 1985 discloses a frequency of 8 to 83% (mean =
45%). This mean is similar to the early findings of BeanXi n
1938: of300 study necropsy patients with coronary h e a dis-
ease, 153 (5 1 %)had intracardiac thrombus. Patients with fatal
 B. F. Waller e t a / . : Intracardiac thrombi-Part 11 53 1

FIG.I Healed myocardial infarction (MI). (A) Two-chamber view of the heart qhowing anteroapical healed MI (black arrows) with peduncu-
lated apical thrombus (white arrows). (B) Close-up of thrombus seen in (A).Thrombus is capsulated. Ao =aorta, LA = left atrium, LV = left ven-
tricle. T = thrombus.

acute MI tend to have a higher frequency of mural thrombus
than those with an old healed infarction.", l 3 Foord found
39% of 3 15 patients with fatal acute MI had intracardiac
thrombi compared with 34% of 107 necropsy patients with
healed MI." Similarly, Jordan and colleaguesI3 4 years later
found 38% of necropsy patients with acute MIShad intracar-
diac thrombus compared with 24% of necropsy of patients
with healed MIS.Anterior infarcts have a greater tendency for
intracardiac thrombus compared with posterior infarcts irre-
spective of infarct age. I , 13, IyThe frequency of mural thrombi
in necropsy patients with anterior myocardial infarcts is near-
ly twice that for posterior (inferior) infarcts.2-'y Multiple in-
farcts (old and new) are more likely associated with intracar-
diac thrombi compared with single infarcts (34% of single vs.
49% for multiple infarcts20).The frequency of mural thrombi

FIG.2 Acute anterior myocardial infarction with mural thrombus

(arrows)(T).The anterior septa1 wall is extremely thin, but a large
niural thromhus is laminated against it simulating a thick ventricular FIG.3 Acute myocardial infarction. Laminated thrombus (mows)
septum (VS). LVFW = left ventricularfree wall. is associated with acute lateral infarction. LV = left ventricle.
532 Clin. Cardiol. Vol. 18, September 1995

Gamin9 did not find patient age a determinant of frequency of

F i c 4 Healed inyocardial infarction. Ventricular section ofthe left
vcntiicle near the apex showing about 1/2 ofthe left ventricularcav-
ity filled by organized thrombus (T).
is proportional to the size of the infarct (Figs. 1-3): large >
medium > small infarcts (93,57, and IS%, respectively13).20
The presence of congestive heart failure, also proportional to
infarct size, is associated with an increased frequency of mural
thrombi in both acute and healed myocardial infarcts.")
mural ventricular thrombus, but Yater and colleagues21found
an increasing frequency of left ventricular thrombi in patients
older than SO years: 56% of these had left ventricular mural
thrombi compared with 3 6 3 7 % of those younger than SO
years.I9
In the setting of atherosclerotic coronary heart disease, right
ventricular thrombi are less frequent than left ventricular
thrombi.?l Garvin9 found left ventricular mural thrombi in
59% compared with right ventricular mural thrombi in 20% of
133 cases of MI. Jordan and colleaguesi3observed left ven-
tricular thrombi to be nearly 10 times as frequent as the right
ventricular thrombi in the setting of coronary heart disease
with left and right ventricular infarcts. Foord" and BeanX
found mural thrombi in 35 and 45% of left ventricular infarcts
compared with 5 and 8% of right ventricular infarcts, respec-
ti~e1y.l~ Of five necropsy studies of right ventricular thrombus
associated with right ventricular infarction (Table II),x-", 1 3 , 23
1-24% of patients with acute or healed myocardial infarcts had
thrombi in the right ventricle. Right ventricular mural thrombi
were nearly always located in the zone of the infarcted right
ventricular wall."^ 13,20Jordan etcth13and Foord" found right
ventricular thrombi more commonly associated with acute
than with healed infarcts (4 and 6% in acute, 1 and 3% i n
healed, respectively). Right ventricular thrombi associaled

1 Intracardiac thrombus: Left ventricular MI (acute, healed, or both) without aneurysm

TAHI.I!
First author (Rcf.) Year No. of necropsy patients No. (%)of patients with thronibus
Wolf (2) I926 23 7 (30)
Parkinson (3) I928 83 14(17)
Lrvine (4) I929 46 3x (83)
I.iu ( 5 ) 1932 100 34 (34)
Meakins (6) I932 62 29 (47)
Appelbauni (7) I935 I so 81 (54)
Bean (X) 1938 300 IS3 ( 5 I )
.' c
Jrl! vlll ( 1)
( 5 ,
1941 133 89 (67)
Hellerstein ( 10) 1947 I60 65(41)
Foord ( I I ) 1948 3IS(AMI) I24 (39)
107 (HMI) 36 (34Y'
Sotlcr'strom( 12) 1948 181 142 (7X)
Jordan ( 13) 19.52 2 10 (AMI) 80 (38)
I I7 (HMI) 2x (24)
Hilden (14) 1961 176 73 (4 I )/'
VA Cooperative ( 15) I973 54 20(37)'
Aber( 16) 1976 24 I 0 (42)
Viser ( 17) 1983 16(AMI) 4 (2.5)
T'ikanioto ( I ) 198.5 13 I@)"
Totals 2270 1028 (4.5)
( 13-422) I1-142(8-83)1
I' I0 patients had left ventricular aneurysms but separate data not provided.
'' 53/92 ( 5 8 % ) not anticoagulated, 20/84 (24%) anticoagulated.
' I 5/3 I (48%) not anticoagulated, 5/23 (22%J)anticoagulated.
"Transplant patients.
Ahhrr,i~irrfioris:AM1 = acute myocardial infarction, HMI =healed myocardial infarction.
 B. F. Waller et al.: lntracardiac thrombi-Part I1 533

TAWLA.
I1 lntracardiac thrombus: right ventricle
First author (Ref.) Yea No. of necropsy patients No. (%)of patients with thrombus Etiology
GarVlIl(0) 1941 I33 MI
Jordan ( 13) 1952 210 AM1
117 HMI
Bean (8) 1938 300 MI
Foord ( I I ) 1948 315 AM1
107 HMI
Garvin (0) 1941 37 MS
Stone (27) 1933 100 MS
Scderstrom ( 12) 1948 76 MS
103 AM1
Totals 1498
( I Thromhus in right ventricle alone or associated with thrombus in other chamber.

Ahbniiiurions: MI =myocardial infarction, AM1 =acute myocardial infarction, HMI = healed myocardial infarction, MS = mitral stenosis

with coronary heart disease are frequently associated with ad-
ditional thrombi in the left ventricle."-" Of a total of 64 ca5es
of right ventricular mural thrombi in the reports of Appelbaum
and Nicolson? Garvin," and Bean,* thrombi were confined to
the righc ventricle in only 9 (24%); in 55 (76%) thrombi were
also in the left ~ e n t r i c l e .Jordan
'~ and colleagues13indicated
that right ventricular thrombi were more likely to occur in pa-
tients with congestive heart failure associated with acute or
healed infarcts. BeanXand Foord" noted that right ventricular
thrombi were more commonly associated with embolic events
(identified at necropsy) compared with left ventricular throm-
bi in the setting of coronary heart disease. Bean8 noted that
75% of patients with right ventricular thrombi had necropsy
evidence of pulmonary emboli compared with 34% of septem-
ic emboli in necropsy patients with left ventricular thrombi.
In the era ofthrombolytic therapy for acute myocardial in-
farction, the effects, if any, on the development of intracardiac
thrombi are unknown. Although early thrombi formation
would be prevented, later formation (e.g., several days after
administration of a thrombolytic agent) of thrombi should not
be afl'ected.
To cummarize, factors associated with increased frequency
of left ventricular thrombus in myocardial infarctions (MI) in-
clude:'-?'
1. 'Transmural versus nontransmural MI
2. Acute versus healed MI
3. Large versus medium versus small MI
4. Anterior versus posterior MI
5. Multiple versus single infarcts
6. Congestive heart failure > no heart failure
7. Age > 50 years versus age < 50 years
8. Left ventricular hypertrophy versus no hypertrophy in
heuled MI
9. Aneurysm versus no aneurysm.
Similarly, factors associated with increased frequency of
~ ~ - l ~ ~ ' ~ ~ setting of coronary heart disease i n c l ~ d e : ~ - ~13,20,23-2y
right ventricularthrombus inMIs i n c I ~ d e : ~ 19,22,23
1. Acute versus healed MI
2. Presence of thrombus versus no thrombus in the left ven-
tricle
3. Congestive heart failure versus no heart failure
4. Large versus small infarct size.
Atrial thrombus within the atrial appendage and/or within
the body of the atrium is commonly seen in patients with
coronary heart disease (Table 111). Many of the necropsy pa-
tients in whom atrial thrombus has been identified had no
underlying atrial infarction but simply had severe ventricular
dysfunction from previous or recent myocardial infarcts, con-
gestive heart failure, or both. Atrial mural thrombus is also
commonly associated with atrial infarction (when present). l 9
Of 192 necropsy cases with atrial mural thrombi, 46 (24%)
had atrial infarctions.12In 3 1 cases of atrial infarct studied by
Cushing et 24 (77%) had atrial mural thrombi. Atrial
thrombi are more common in the right atrium, consistent with
the greater frequency of infarction of the right versus the left
20, 23, 24 In the studies of Cushing et uL.*~, 19
patients had right atrial thrombi, 1 had left atrial thrombi, and
4 had biatrial thrombi. In the majority of instances the throm-
bi are located in the atrial appendage and associated with re-
cent atrial infarct. In all 46 cases reported by Soderstrom,I2
the atrial thrombus was in the right atrium.I9 Atrial thrombi,
when present, are usually associated with left ventricular
thrombi.19Jordan and colleagues13observed atrial thrombi in
9.5% of patients with acute MI and in 9.4% of patients with
healed MIS.In contrast, Foord' noted atrial thrombi in 9% of
patients with fatal acute MIScompared with 18% of necropsy
patients with healed MIS. Jordan et al. l 3 noted atrial thrombi
with acute MI were associated with atrial fibrillation and con-
gestive heart failure in 5% and 45% of patients, respectively.
In contrast, Jordan et al. l 3 found atrial thrombi with healed
MI were associated with atrial fibrillation in 36% and with
congestive heart failure in 9 1%.
In summary, associated conditions of atrial thrombi in the
' ' 9 %
534 Clin. Cardiol. Vol. 18, September 1995

'IXiji i; 111 Intracardinc thrombus: right atrium

First author (Rel.) Year No. ofnecropsy patients No. (%)ofpatients with thrombus Etiology

Soderstroni ( 12) I948 I92 46 (24)" Atrial infarction"

Cushing (24) 1942 31 27 (77) Atrial infarction"
Cnrvin (9) I941 133 29 ( 2 2 ) MI
Jordan ( I.?) I952 210 20 (9) AM1
I I7 8 (7) HMI
Foord ( II ) I948 315 15 ( 5 ) AM1
107 14(13) HM I
clalvln(9)
: 1941 37 19(51) MS
Graham ( 25 ) 101 31 (31) MS
Jordan (26) 1951 51 24 (47) MS
Laws (27) 1933 I48 28(19) MS
CiKlef(28) 1937 178 10(6) MS
Hahne (29) 1962 27' vllrious causes
Totals 1498 I I6 (8)
(IThroinhus in right atrium only or associated with thrombus in other chamber.
"Associated with left ventricularinfarction and thrombus.
' Review o f 2 5 previously reported cases. All had"ba1l valve" thrombi.
Ahhreviations as i n Tables I and 11.

I . Underlying atrial infarction > no atrial MI
7. Right atrium > left atrium
3. Commonly associated with left ventricular thrombi
4. Healed atrial > a c u t e atrial MI
5. Atrial fibrillation > sinus r h y t h m
6. Congestive heart failure > no heart failure.
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