E-wave propagation index and left ventricular thrombus after STEMI: adding flow dynamics to echocardiographic risk assessment

Left ventricular (LV) thrombus remains a clinically relevant complication of ST-elevation myocardial infarction (STEMI) despite major advances in reperfusion strategies and medical treatment.1 Although its incidence has declined in the era of primary percutaneous coronary intervention (PCI), LV thrombosis continues to occur in a non-negligible proportion of patients, particularly those with large anterior infarctions, reduced left ventricular ejection fraction (LVEF), and apical regional wall motion abnormalities.1,2 The clinical importance of LV thrombus is driven by its association with systemic embolization, most notably ischaemic stroke, and by its implications for anticoagulation therapy and follow-up imaging strategies.3 Detection of LV thrombus relies on multimodality imaging.1,3,4 Transthoracic echocardiography is widely available and represents the cornerstone of initial evaluation, yet its sensitivity is limited, especially in patients with suboptimal acoustic windows or small mural thrombi. The use of contrast-enhanced echocardiography substantially improves diagnostic accuracy but is not uniformly applied in routine practice. Cardiac magnetic resonance (CMR) imaging, particularly with the use of first pass perfusion imaging5 and late gadolinium enhancement (LGE),6 is considered the reference standard because of its superior spatial resolution and tissue characterization. However, CMR is resource-intensive, not universally available, and often reserved for selected patients. These limitations highlight the need for simple, reproducible, and cost-effective echocardiographic parameters that can help identify patients at high risk of LV thrombus formation and potentially guide the use of advanced imaging techniques such as CMR.