Apical LV Thrombus

 

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A bright echodense mass is seen in the apex is suggestive of an apical thrombus.
This individual has had a prior anterior wall and apical infarct. Note the severe hypokinesis to akinesis of these segments, making an LV thrombus the most likely diagnosis.

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These can sometimes be small and are often missed. Off axis imaging as shown here is helpful to look for these, especially when this degree of apical wall motion deficit is seen.

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Additional orthogonal views confirm the finding. Here is the 4 chamber view.