Abstract
Introductionleft ventricular thrombus (LVT) may lead to thromboembolism and has been associated with increased morbidity and mortality. Little is known about the incidence, etiology and outcomes in patients with LVT in Africa. The objective was to determine the etiology, treatment practices, rate of resolution and clinical outcomes in patients with LVT in the region.Methodsa review of all echocardiograms performed in 2017 and 2018 at the Aga Khan University Hospital, Nairobi was carried out and patients with LVT identified. Physician review of charts was performed to document clinical characteristics and outcomes.Resultsduring the study period 100 patients with LVT were identified (1.3% of adult echoes). The mean LVEF was 28.5% (±11.0%) and 88 (88%) patients had an LVEF of less than 40%. Underlying etiology of LV dysfunction was post myocardial infarction (MI) in 28 (28%), chronic ischemic cardiomyopathy in 42(42%) and non-ischemic cardiomyopathy in 30 (30%) patients. In 15 (15%) patients a stroke or TIA predated the diagnosis of LVT. Long term anticoagulation was given to 92 (92%) patients. Among these, 34 (37%) received warfarin while 58 (63%) were treated with a DOAC. In the 64 patients who had reassessment imaging (median duration 177 days), complete thrombus resolution was noted in 38 (59.4%). One-year clinical outcome data was available for 85 patients: 13 (15.3%) patients had died, 4 (4.7%) had suffered a stroke, and 8(9.4%) had had a bleeding episode. Rates of thrombus resolution (warfarin 64%, DOAC 55.6%, p=0.51), stroke (warfarin 2.9%, DOAC 1.7%, p=1.0) and bleeding (warfarin 5.9%, DOAC 5.2%, p = 1.00 were not significantly different among patients treated with warfarin and DOAC.Conclusionwe noted a high incidence of LVT compared to contemporary Western series. The majority of our patients were treated with DOACs. There were no significant differences in outcomes between patients treated with a DOAC and those receiving warfarin. Prospective evaluation on the efficacy and safety of DOACs for this indication is needed.
Highlights
Development of left ventricular thrombus (LVT) in patients with systolic dysfunction is associated with systemic embolism and increased morbidity and mortality [1, 2]
In our series we found no significant differences in rate of thrombus resolution, stroke and bleeding among patients treated with warfarin and directly acting oral anticoagulant (DOAC)
This study provides important insights into patterns of formation and resolution of LVT and clinical outcomes in patients in an African referral hospital
Summary
Development of left ventricular thrombus (LVT) in patients with systolic dysfunction is associated with systemic embolism and increased morbidity and mortality [1, 2]. Most series have studied LVT following myocardial infarction. In the 1980s, the reported incidence of post MI LVT was 17% overall, and up to 46% in patients with anterior MI. A 1988 study of serial echoes in 60 patients with LVT post MI reported a thrombus resolution rate of 40% during a mean follow-up of 24 months. In a more recent retrospective study of 128 patients thrombus resolution occurred in between 40% to 100% of patients on repeat imaging at one year depending on the agent used for anticoagulation, embolic events in only 1.9% and death in 13% [6]. The 2017 ESC guidelines for STEMI recommend treatment of LVT with oral anticoagulation for up to six months guided by repeated imaging, but no agent preference is given [9]
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