Thick apex on FoCUS

A middle-aged male presented to the ED with dyspnea. He had a history of both severe ischemic cardiomyopathy, as well as poor adherence to outpatient care. He had not seen a physician in 2 years.

He was mildly hypoxic, and had clinical signs suggestive of heart failure. Point-of-care thoracic ultrasound demonstrated US B-lines. A focused cardiac ultrasound was performed, and apical 4-chamber view obtained.

What does the echo show?
There is marked systolic dysfunction, which is not significantly different than his prior echo report suggested. However, in contrast to the thin septal wall, the apex appears  thick, but akinetic. It also seems oddly trabeculated.

Sometimes, an obliquely directed A4C view can produce a foreshortened and thick "apex," but that isn't the case here. This is instead a left ventricular thrombus. 

LV thrombi can form in the LV, especially following a large anterior MI that produces a large region (especially the apex) of akinesis. These used to be more common in the past, but are only infrequently seen now in the days of lytics and PCI.

The rate of embolic complications appears to have decreased in the reperfusion era. Treatment with lytics, heparin, or oral anticoagulants haven't shown an unequivocal benefit. Given this patient's problems with adherence, anticoagulation was defered.

Reference
Left ventricular thrombus formation after acute myocardial infarction