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Background: Left ventricular (LV) thrombus is reported in 4-17% of patient following acute myocardial infarction in the era of reperfusion therapy. This diagnosis has significant implications for patients in terms of risk of embolic complications and anticoagulation requirements.Aim: We hypothesized that recent improvements in Echo equipment technology may reduce the need for contrast agents for the diagnosis of LV thrombus in this setting.Methods: We reviewed the records of consecutive patients presenting to our institution with ST elevation MI (STEMI) and recorded the results of echocardiography using latest generation equipment, use of contrast and diagnosis of LV thrombus.Results: 489 patients presented with STEMI between 01 Jan 2009 and 31 May 2010. 468 of these underwent at least one transthoracic echocardiogram. Median time to first echocardiogram was 1 day. It was possible to rule out thrombus in 407 (87%) patients. However, it was only possible to confidently diagnose LV thrombus in 6 patients (12 studies). In 57 studies (48% of studies with suspicion of thrombus) the diagnosis or exclusion of LV thrombus could not be made, despite the use of contemporary, high end scanners. Contrast was subsequently utilised in 40 of these studies and this confirmed the presence of thrombus in 13 studies and excluded it in the remainder.Conclusion: LV thrombus is not an uncommon diagnosis following STEMI and has significant implications for patient care. Despite significant improvements in the resolution and image quality of contemporary ultrasound systems, contrast is still required in a substantial proportion of studies to rule in or out the presence of LV thrombus.