Heart failure represents a major and growing public health problem because of its prevalence, incidence, morbidity, mortality and economic costs. The prevalence of HF is 2% to 3% of general population . Five million Americans are affected, with more than 530000 cases diagnosed each year . The mortality rate from severe HF remains >60% within 5 years of diagnosis and that of 50% of hospitalized patients with HF required readmission to hospital within 6 months of discharge. The estimated costs of HF amounted to >35 billion $ per year in the USA . The development of LVT is a well-known complication in various cardiac conditions with the highest rate observed in acute anterior myocardial infarction and congestive HF reached to 10-30% [4,5]. As a result of severe left ventricular systolic dysfunction [6,7]. Rabbani et al found that the incidence of LVT remain persistently high reached to (35%) for Acute Myocardial Infarction (AMI) involving the anterior wall .
The prevalence of LVT, especially in early Percutaneous Intervention (PCI) facilities are found to be reduced with estimation ranging between 5% and 15% [9,10]. Solheim et al, reported an incidence of LVT within 3 months of AMI in selected patients managed with primary PCI was 15% . The constellation of endothelial injury, hypercoagubility and blood stagnation, which are well described previously as Virchows triad, for formation of the thrombus [11,12]. In AMI, other predisposing factors also play a role in the development of LVT such as large infarct size, severe apical a synergy, LV aneurysm and anteroposterior myocardiac infarction. The early recognition of LVT is vital to prevent the unwanted sequel of systemic thromboembolic events [6,11,12]. Currently in Yemen the well-known diagnostic system applied in majority health center and hospitals is Transthoracic Echocardiography (TTE) which is easily accessible and believed to have over 85% accuracy in proper imaging results [13-15].
However, care must be taken to exclude false positive results which occasionally may occurred [16,17]. Improved LV cavity assessment and thrombi detection using TTE contrast studies were noted to be better than non-contrast TTE, especially for mural (Laminar) and smaller thrombus . Although several therapies as B-blockers, Angiotensin Converting Enzymes (ACE) inhibitors and cardiac resynchronization therapy have been proven effective in improving HF outcomes, many questions about optimal treatment remain yet un-answered. The magnitudes of heart failure and left ventricular thrombus have not been yet studied in Yemen. We carried out this study to determine the prevalence of heart failure with LVT among Yemeni patients admitted into Kuwait Teaching Hospital in Sanaa City.
We reviewed all files of patients admitted to the hospital between January 2014 to 2017 whom had heart failure based on Framingham clinical major and minor criteria for the diagnosis of HF .
Major criteria include the following:
· Paroxysmal nocturnal dyspnea.
· Weight loss of 4.5 kg in 5 days in response to treatment.
· Neck vein distention.
· Acute pulmonary edema.
· Hepatojugular reflux.
· S3 gallop.
· Central venous pressure greater than 16 cm water.
· Circulation time of 25 seconds.
· Radiographic cardiomegaly.
· Pulmonary edema, visceral congestion, or cardiomegaly at autopsy.
Minor criteria are as follows:
· Nocturnal cough
· Dyspnea on ordinary exertion
· A decrease in vital capacity by one third the maximal value recorded
· Pleural effusion
· Tachycardia (rate of 120 bpm)
· Bilateral ankle edema
The diagnosis of HF was by 2 major or 1 major and 2 minor criteria.
Special form was designed to record demographic data clinical presentation and all investigations including echocardiogram, chest X-ray and ECG. The Echo procedure was performed using vivid 3 GE machine with adult prop transducer with frequency from 1.5-5 to ensure adequate imaging analysis. The diagnosis of LVT was made using the following criteria (20):
· A distinct echogenic mass within the left ventricle cavity (may be sessile/layered or protruding/mobile) that is contiguous with, but acoustically distinct from the underlying endocardial surface .
· It is seen throughout the cardiac cycle and visualized on at least 2 orthogonal views, an associated underlying region of severe wall motion abnormality, usually severe hypokinesis,akinesis, dyskinesis, or aneurysmal dilatation .
· Rarely, LVT forms in regions of stunned myocardium that has recovered normal wall motion at the time of detection .
· Spontaneous Echo Contrast (SEC) or smoke is commonly seen within the left ventricle of patients with Intracardiac thrombi and is believed to be due to the interaction of red cells and plasma proteins in situations of low, stagnant flow .
· The presence of SEC in association with marked wall motion abnormalities should warrant a high suspicion for the presence of left ventricle thrombus .
· Given the propensity for thrombi to form at the apex of the left ventricle, the best imaging planes to visualize left ventricle thrombus are the apical views, where the transducer is closest to the region of interest .
· Certain normal anatomic structures (papillary muscles, false tendons, and trabeculations) and technical artifacts (reverberations, near-field artifacts) will result in false positive diagnoses of left ventricle thrombus .
· The use of higher frequency transducers has been shown to overcome some of these limitations due to higher spatial resolution and reduced artifacts .
Left ventricular dimensions were determined by the leading edge to leading edge method [6,16]. Left Ventricular Ejection Fraction (LVEF) was determined based on the recommendation of American Society of Echo (ASE) and European Society of Echo . Dilated cardiomyopathy was diagnosed in the presence of globular LV dilatation with LVDD>56 mm and EF <40% . Diagnosis of Myocardial Infarction (MI) was based on combination of documented history of chest pain, ECG abnormalities and segmental wall motion abnormalities . Peripartum cardiomyopathy was diagnosed on the basis of temporal relation of HF to last pregnancy and delivery as proposed in ESC guideline . Hypertensive Heart Disease (HHD) was diagnosed in hypertensive patients documented by history and the presence to concentric or eccentric LV hypertrophy or concentric LV remodeling, left atrial dilatation and/or systolic and/or diastolic dysfunction . Diagnosis of Rheumatic Heart Disease (RHD) was made using the World Heart Federation criteria .
Data was verified and Interred to PC, and analyzed using SPSS V16.0, AP. Variables were presented as proportions, and the differences were tested using Pearsons chi-square test. P value of ≤ 0.05 was considered significant.
The total numbers of patients admitted into the medical wards with heart diseases during the study period were 1856 patients. Of them 217 patients (11.7%) were suffering from heart failure. Among those patients of heart failure there were 61 (28.1%) patients had left ventricular thrombosis. Distribution of patients with heart failure according to age and sex is shown in table 1. There were significance differences between age and sex of both groups of patients with LVT and those without LVT. The mean age of patients with LVT was 51 ± 8.1 years and that without LVT was 60 ± 2.3. In there were only 7 (11.4%) below 30 years old and 30 (49%) were >50 years in heart failure with LVT. Heart failure was more frequent in males patients than in females in both groups (HF with LVT and HF without LFT).
We analyzed several risk factors that may play significant role in the development of left ventricular thrombus among patients with heart failure, we found that Ischemic heart diseases is the significant risk factor for development LVT with Value of (<0.0001) see table 2.
Further work -up of ischemic heart diseases and DCMP on both groups of patients we found that Antero-lateral ischemia presented in equal percentage in both group ,while dilated cardiomyopathy was found in HF with LVT more than HF without LVT accounted for (34.2% and 10%) respectively table 3 and figure 1.
The internal dimensions of LV was measured using echocardiography revealed that, the Left Ventricular End Diastolic Dimensions (LVEDD) among HF patients with LVT was higher than that with HF without LVT with a mean value of (67.18mm versus 55mm). Similarly the mean Ejection Fraction (EF) of HF with LVT was 32.39% while the mean EF in patients with HF without LVT was 47.97% with significant P value <0.0001, see table 4 and figure 2.
There were 34 patients who had arrhythmia in both groups of patients; however the frequency was more among HF with LVT than HF without LVT (21% versus 13%). The most common ECG findings were Left Bundle Branch Block (LBBB) in both HF patients with and without LVT, see table 5 and figure 3.
The complications were recorded in 19 patients, ischemic stroke found in 6 patients (10%) in HF with LVT and in 10 patients (6.4%) in patients with HF without LV. Other complications such as mesenteric ischemia and lower limb ischemia were less frequent in both groups table 6 and figure 4.
The outcome of patients in this study was divided into 2 groups, patients improved & discharged with acceptable condition without surgical interventions were 209 patients (93.4%), 57 (93.4%) with HF and LVT and 152 (97.4%) with HF without LVT. 8 patients died during hospitalization in both groups HF with LVT 4 (6.6%) and HF without LVT 4 patients (2.6%) this did not reach to statistic significant P. value 0.161 see figure 5.
The prevalence of LVT among patients with heart failure in this study was 28.1%. This prevalence is higher than that was reported from Pakistan, USA which found the prevalence ranged between 11%-20% [30-33]. But coincide with prevalence rate from Egypt . This is because most of our cases were cardiomyopathy and ischemic cases and they attended hospital late, also because of poverty most of our cases did not receive thrombolytic therapy or underwent primary PCI. In our study the mean age of HF patients with LVT was 51 years and considered to be less than the mean age reported from Egypt and Pakistan which reported 57and 54 respectively [34,35]. These differences may be related to life expectancy, the average age of life expectancy in Yemen is 55 years while life expectancy in other countries is more than 60 years.
In our study most cases with HF and LVT were males, this phenomena was reported from Egypt, Pakistan and USA table7 we know that ischemic heart diseases and cardiomyopathy which are the risk factors for (LVT) are more prevalence in males than females. Risk factors such as Smoking, Diabetes mellitus had no significant role in HF with LFT in our study see figure 6 and figure 7. This result contradicts with other studies reported from Egypt and Pakistan. In this regard a separate study may be required to enable us to highlight these differences.
We found the highest prevalence of HF with LVT in Ischemic heart diseases 31 (51%) most of them with anterolateral infarction. This result goes in line with results reported from other countries [34-36]. Left ventricular thrombus is well documented as a complication of MI with a prevalence varying from 60% in prethrombotic era to between 5%-15% in the setting where PCI is instituted [7,9]. Most of the patients with LVT in our study had anterolateral involvement with dilated LV and reduced EF. Higher prevalence of LVT following anterolateral MI compared to non-anterior MI was reported from other studies too . Dilated Cardiomyopathy accounted for the second highest prevalence among HF with LVT in this study accounted for (34.2%).This in keeping with other reports [38,39].
DCMP is associated with dilatation of both right and left ventricles with reduced overall LV systolic function, the resultant biventricular stasis promotes the formation of the thrombus, most frequently in the LV, possible explanation is at chewing habit in our country which is known to induce tachycardia and possible tachycardia induced myopathy. Hypertensive heart disease is regarded to be an important cause of HF all over the world. In our study it was the 3rd cause of HF with LVT associated with impaired LV systolic function this can be explained by drug noncompliance where we found that most of our patients had uncontrolled hypertension . Overwhelming majority of our cases had high LVDD and low EF. Previous studies reported increased LVDD and low EF to be independent predictors of LVT Formation [19,25].
Information on LVT complicating hypertensive heart disease without MI or DCMP is scarce. The role of hypertension in enhancing prothrombotic or hypercoagulable state by impacting on all components of the Virchows triad termed the thrombotic paradox of hypertension or Birmingham paradox was reported by Lip . In the study of Framingham offspring study, Poli and colleagues reported an association between blood pressure and plasma PA-1 and tPA antigen levels suggesting impaired fibrinolysis with increasing blood pressure .
Rheumatic heart disease in general, is still one of the causes of HF and hospital admission in our country, but in this study it was an uncommon cause of LVT, two patients were observed they have severe chronic Rheumatic Mitral incompetence with dilated and poorly contractile LV. We speculate that LVT observed in these patients is a result of increased LVDD and low EF rather than the rheumatic etiology of the valve lesion in comparing the echocardiography findings in our patients we found significant difference between HF patients with LVT and those without LVT which including (EF,LVEDD,LVESD). This observation goes with results seen in other literature in Egypt, Pakistan and USA [33-38].
In this study thromboembolic complication of HF with LVT is 13.1% similar to the study conducted in Nigeria in which the thromboembolic complications at the time of presentation were 13% . Mortality during hospitalization reached to (3.6%) and no differences found between HF with LVT OR HF without LVT. This result is not compared to other studies because of limitation of retrospective study in our situation and the causes of death may be not related to presence of thrombus in LV and the information available may be not adequate to explain the mortality.
Heart failure is still one of the important causes of admission in our hospital and LV thrombus as a complication of HF is higher when comparing with developed countries.
Prospective study is needed to recognized risk factors and long term complication of heart failure with left ventricular thrombus.
We express our deep thanks to Esmaeel Gahaf and Arab Board carrier for the contribution in assisting data analysis.
1. Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski p, et al. ESC Guidelines for guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: Task Force for Diagnosis and treatment of acute and chronic Heart Failure 2008 of European Society of cardiology. Developed in collaboration with the heart failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM) (2008) Eur Heart J 29: 2388-2442. https://doi.org/10.1093/eurheartj/ehn528
2. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, et al. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults; a report of the American college of cardiology Foundation/American Heart Association Task Force on practice Guidelines: Developed in Collaboration with the internatiocnal Society for Heart and Lung Transplantation (2009) Circulation 119: e391-e479. https://doi.org/10.1161/CIRCULATIONAHA.109.192065
3. Rosamond W, Flegal K, Furie K, Hailpern SM, Howard V, et al. Heart disease and stroke statistics-2008 update :a report from the American Heart Association Statistics Committee and stroke statistics Subcommittee (2008) Circulation 29: e25-e146. https://doi.org/10.1161/CIRCULATIONAHA.107.187998
4. Ciaccheri M, Castelli G, Cecchi F, Nannini M, Santoro G, et al. Lack of correlation between intracavitary thrombosis detected by cross sectional echocardiography and systemic emboli in patients with dilated cardiomyopathy (1989) Br Heart J 62: 26-29. http://dx.doi.org/10.1136/hrt.62.1.26
5. Gottdiener JS, Gay JA, VanVoorhees L, DiBianco R and Fletcher RD. Frequency and embolic potential of left ventricular thrombus in dilated cardiomyopathy: assessment by 2-dimensional echocardiography (1983) Am J Cardiol 52: 1281-1285. https://doi.org/10.1016/0002-9149(83)90588-X
6. Billingsley IM and Leong-poi H. Left ventricular thrombus: diagnosis, prevention and management (2005) Cardiology Rounds 10.
7. Nayak D, Aronow WS, Sukhija R, McClung JA, Monsen CE and Belkin RN. Comparison of frequency of left ventricular thrombi in patients with anterior wall versus non-anterior wall acute myocardial infarction treated with antithrombotic and antiplatelet therapy with or without coronary revascularization (2004) Am J Cardiol 93: 1529-1530. https://doi.org/10.1016/j.amjcard.2004.02.066
8. Rabbani LE, Waksmonski C, Iqbal SN, Stant J, Sciacca R, et al. Determinants of left ventricular thrombus formation after primary percutaneous coronary intervention for anterior wall myocardial infarction (2008) J Thrombosis and Thrombolysis 25: 141-145. https://doi.org/10.1007/s11239-007-0064-2
9. Kalra A and Jang KI. Prevalence of early left ventricular thrombus after primary coronary intervention for acute myocardial infarction (2000) J Thrombosis and Thrombolysis 10: 133-136.
10. Solheim S, Seljeflot I, Lunde K, Bjørnerheim R, Aakhus S, et al., Frequency of left ventricular thrombus in patients with anterior wall acute myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy (2010) Am J Cardiol 106: 1197-1200. https://doi.org/10.1016/j.amjcard.2010.06.043
11. Delewi R, Zijlstra F and Piek JJ. Left ventricular thrombus formation after acute myocardial infarction (2012) Heart 98: 1743-1749. https://doi.org/10.1136/heartjnl-2012-301962
12. Nair A, Sealove B, Halperin JL, Webber G and Fuster V. Anticoagulation in patients with heart failure: who, when, and why? (2006) Eur Heart J 8: E32-E38. https://doi.org/10.1093/eurheartj/sul029
13. Weinsaft JW, Kim HW, Crowley AL, Klem I, Shenoy C, et al. LV thrombus detection by routine echocardiography: insights into performance characteristics using delayed enhancement CMR (2011) JACC 4: 702-712. https://doi.org/10.1016/S0735-1097(11)60784-5
14. Visser CA, Kan G, David GK, Lie KI and Durrer D. Two dimensional echocardiography in the diagnosis of left ventricular thrombus. A prospective study of 67 patients with anatomic validation (1983) Chest 83: 228-232.
15. MB Srichai, Junor C, Rodriguez LL, Stillman EA, Grimm AR, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation (2006) Am Heart J 152: 75-84. https://doi.org/10.1016/j.ahj.2005.08.021
16. Armstrong WF, Feigenbaum H and Ryan T. Masses, tumors and source of embolism, in Feigenbaums Echocardiography (7th edn) (2010) Lippincott Williams and Wilkins, Philadelphia, Pa, USA.
17. Weinsaft JW, Kim RJ, Ross M, Krauser D, Manoushagian S, et al. Contrast-enhanced anatomic imaging as compared to contrast-enhanced tissue characterization for detection of left ventricular thrombus JACC: Cardiovascular Imaging 2: 969-979. https://doi.org/10.1016/j.jcmg.2009.03.017
18. Mansencal N, Nasr IA, Pillière R, Farcot JC, Joseph T, et al. Usefulness of contrast echocardiography for assessment of left ventricular thrombus after acute myocardial infarction (2007) Am J Cardiol 99: 1667-1670. https://doi.org/10.1016/j.amjcard.2007.01.046
19. Lioyd-Jones DM, Larson MG, Leip E, etal .Lifetime risk for developing congestive heart failure: the Framingham heart study (2002) circulation 106: 3068-3072. https://doi.org/10.1161/01.CIR.0000039105.49749.6F
20. Left Ventricular Thrombus: Diagnosis, Prevention, and Management from 2005 Division of Cardiology, Michaels Hospital, University of Toronto, Published in Cardiology Rounds SNELL Medical Communication Inc.
21. Bettari L1, Fiuzat M, Becker R, Felker GM, Metra M, et al. Thromboembolism and Antithrombotic Therapy in Patients With Heart Failure in Sinus Rhythm Current Status and Future Directions (2011) Circ Heart Fail 4: 361-368. https://doi.org/10.1161/CIRCHEARTFAILURE.110.959957
22. Merino A, Hauptman P, Badimon L, Badimon JJ, Cohen M, et al. Echocardiographic smoke is produced by an interaction of erythrocytes and plasma proteins modulated by shear forces (1992) J Am Coll Cardiol 20: 1661-1668. https://doi.org/10.1016/0735-1097(92)90463-W
23. Asinger RW, Mikell FL, Sharma B and Hodges M. Observations on detecting left ventricular thrombus with two-dimensional echocardiography: emphasis on avoidance of false positive diagnoses (1981) Am J Cardiol 47: 145-156. https://doi.org/10.1016/0002-9149(81)90303-9
24. Lang RM, Bierig M, Devereux RB, Foster E, Solomon SD, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiographys guidelines and standards committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology (2005) J Am Society Chocardiography 18: 1440-1463. https://doi.org/10.1016/j.echo.2005.10.005
25. Armstrong WF and Ryan T. Dilated Cardiomyopathy (7th edn) (2010) Feigenbaums Echocardiography, Lippincott Wilkins and Wilkins, Philadelphia, Pa, USA.
26. Armstrong WF and Ryan T. Echocardiography and coronary artery disease, in Feigenbaums Echocardiography (7th edn) (2010) Lippincott Williams and Wilkins, Philadelphia, USA, pp: 427-472.
27. Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy (2010) Eur J Heart Failure 12: 767-778. https://doi.org/10.1093/eurjhf/hfq120
28. Ganau A, Devereux RB, Roman MJ, Pickering GT, Laragh JH, et al. Patterns of left ventricular hypertrophy and geometric remodeling in essential hypertension (1992) J Am Cardiol 19: 1550-1558. https://doi.org/10.1016/0735-1097(92)90617-V
29. Reményi B, Wison N, Steer A, Vaghela V, Mvungi R, et al. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease-an evidence-based guideline (2012) Nat Rev Cardiol 9: 297-309. https://doi.org/10.1038/nrcardio.2012.7
30. Stewart S, Wilkinson D, Hansen C, Vaghela V, Mvungi R, et al. Predominance of heart failure in the Heart of Soweto study cohort: Emerging challenges for urban African communities (2008) Circulation 118: 2360. https://doi.org/10.1161/CIRCULATIONAHA.108.786244
31. Fusster V, Gersh BJ, Giuliani ER, Tajik AJ, Brandenburg RO, et al. The natural history of idiopathic dilated cardiomyopathy (1981) Am J Cardiol 47: 525-530.
32. Wilensky RL and Jung SC. Thromboembolism in patints with decreased left ventricular function: incidence, risk, and treatment (1995) J Cardio Vasc Risk 2: 91-96.
33. Roberts WC, Siegel RJ and McManus BM. Idiopathic dilated cardiomyopathy: analysis of 152 necropsy patients (1987) Am J Cardiol 60: 1340-1355. https://doi.org/10.1016/0002-9149(87)90618-7
34. Fathy A, Ibrahim G and Shaker A. Assesment of mitral anular velocities by dopplar by dopplar tissue imaging in predicting left ventricular thrombus formation after first anterior acute myaocardial infarction (2011) Egyptian Heart J 63: 153-159. https://doi.org/10.1016/j.ehj.2011.08.039
35. Rathi N, Maheshwari N, Kumara D, Sacchdewani RK, Memon NA, et al. Left ventricular thrombus in myocardial infarction (2009) Pakistan heart J 42: 9-13.
36. Henry ford health system. Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction from Henry Ford heart and vascular institute, Detroit. (1998) 47th Annual Scientific session of the American college of cardiology, Atlanta, USA.
37. Asinger RW, Mikell FL, Elsperger L and Hodges M. Incidence of left-ventricular thrombosis after acute transmural myocardial infarction-Serial evaluation by two-dimensional echocardiography (1981) NEJM 305: 297-302. https://doi.org/10.1056/NEJM198108063050601
38. Fuster V, Gersh BJ, Giuliani ER, Tajik AJ, Brandenburg RO, et al. The natural history of idiopathic dilated cardiomyopathy (1981) Am J Cardiol 47: 525-530. https://doi.org/10.1016/0002-9149(81)90534-8
39. Sharma ND, McCullough PA, Philbin EF and Weaver WD. Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction (2000) Chest 117: 314-320. https://doi.org/10.1378/chest.117.2.314
40. Khaled A, Mohammed B and Faiza A. Uncontrolled Hypertension among treated hypertensive patients (2018) J Clini Cardiol Cardiovas Med 2: 22-26. https://doi.org/10.33805/2639.6807.114
41. Lip GYH. Hypertension andthe prothrombotic state (2000) J Human Hypertension 14: 687-690.
42. Poli KA, Tofler GH, Larson MG, Evans JC, Sutherland PA, et al. Association of blood pressure with fibrinolytic potential in the Framingham offspring population (2000) Circulation 101: 264-269. https://doi.org/10.1161/01.CIR.101.3.264
43. Talle TM, Buba F and Anjorin OC. Prevalence and etiology of left ventricular Thrombus in patients undergoing Transthoracic Echocardiography at the University of Teaching Hospital (2014) Adv Med. http://dx.doi.org/10.1155/2014/731936
Alaghbari Khaled, Associated professor of internal Medicine, Sanaa University, Yemen, Tel: +96-7711118376, Email: firstname.lastname@example.org
Khaled A and Faiza A. The prevalence of left ventricular thrombus among heart failure patients admitted to Kuwait teaching hospital in Sanaa City between January 2014 -2017 (2019) Nursing and Health Care 4: 29-34.
Left ventricular thrombus, Heart failure, Yemeni patients.