Left Ventricular Apical Thrombus Research Articles

Evaluation of the efficacy and safety of rivaroxaban compared to warfarin in patients with left ventricular apical thrombus: a randomized clinical trial

IntroductionThis research is one of the pioneering randomized clinical trials (RCTs) aimed at assessing the effectiveness and safety of rivaroxaban in treating left ventricular thrombus (LVT) in patients who have experienced acute coronary syndrome (ACS).Materials and methodsThis is a randomized, controlled, interventional, open-label study. The patients were randomly divided into warfarin and rivaroxaban groups. We performed transthoracic echocardiography at the start of the study and again after three months to measure the thrombus area in square millimeters. The morphology of the thrombus was categorized into mural and round, and the mobility was classified into immobile, semi-mobile and hypermobile. We also monitored for adverse events including bleeding, systemic embolic occurrences, rehospitalization, and major adverse cardiac events (MACE).ResultsThe study included fifty-two patients in the intention-to-treat analysis, with an equal split between the rivaroxaban and warfarin groups (26 patients each). The average follow-up duration was three months. The thrombus resolution rates in the rivaroxaban (76.9%) and warfarin (69.2%) groups, as well as the thrombus size reduction, did not show statistical significance between groups. All semi-mobile or hypermobile thrombi transformed into immobile and all of the round LVTs changed into a mural in both rivaroxaban and warfarin groups. No significant difference was observed in bleeding complications and rehospitalization between the two groups.ConclusionThe trial demonstrated that rivaroxaban is as effective as warfarin in terms of thrombus resolution rate, reduction in thrombus size, bleeding risk, and rehospitalization rate. Our findings suggest that rivaroxaban is a viable alternative to warfarin for managing left ventricular thrombus.Graphical

Left Ventricular Apical Pseudoaneurysm: A Case Report Incidental Diagnosis and Management

Left ventricular pseudoaneurysm (LVPA) is a rare and life-threatening condition characterized by “an outpouching resulting from a rupture in the ventricular free wall.” We present a case with a history of myocardial infarction and left ventricular (LV) apical thrombus who presented with worsening dyspnea. Echocardiography revealed LVPA with bidirectional flow, confirmed by cardiac CT. He underwent successful surgical repair of LVPA and coronary artery bypass grafting. LVPA is associated with significant morbidity and mortality, so early diagnosis is crucial. This case report highlights the successful management of LVPA, underscoring the importance of prompt diagnosis and multidisciplinary care.

Relationship of MAPH Score with Left Ventricular Apical Thrombus and Adverse Events in Patients with Acute Anterior ST-Elevation Myocardial Infarction

Relationship of MAPH Score with Left Ventricular Apical Thrombus and Adverse Events in Patients with Acute Anterior ST-Elevation Myocardial Infarction

Abstract 18811: Heart Failure in a Carrier of Danon Disease

Background: Danon Disease is a rare X-linked dominant genetic condition characterized by hypertrophic cardiomyopathy, skeletal muscle myopathy, and intellectual disability, among other serious complications. The disease is a lysosomal storage disorder in which a mutation in the LAMP-2 gene causes a defect in the lysosome membrane and an accumulation of glycogen in vital tissue including cardiac muscle cells. It occurs more commonly in males, who are also more severely affected than females with this condition. There are no specific treatments available, although studies involving gene therapy have been ongoing. Patients with Danon Disease often require heart transplantation as treatment for end-stage heart failure. Description of Case: A 37-year-old female with a known family history of Danon Disease was discovered to be a carrier of the LAMP-2 mutation after presenting to the hospital with dizziness and palpitations. An echocardiogram obtained at the time of diagnosis revealed left ventricular hypertrophy and left ventricular apical thrombus with normal ejection fraction. She was started on anticoagulation and began following closely with a heart failure clinic. Since diagnosis, she has had multiple echocardiograms which have shown a steady decline in her ejection fraction to 25% and biventricular failure. An ICD was placed, with no shocks ever administered. She has had multiple hospital admissions for exacerbations of heart failure since diagnosis. Telemetry monitoring during these admissions revealed frequent premature ventricular contractions attributed to the patient’s severe cardiomyopathy. Despite continuation of guideline-directed medical treatment, this patient’s systolic heart failure is anticipated to continue worsening. She will likely require heart transplant, for which evaluation has already been initiated. Discussion: Danon Disease is a rare lysosomal storage disorder that often involves progressively worsening cardiomyopathy. Individuals with a known family history of this condition should be referred early for genetic testing. If found to have the condition or be a carrier, they should begin following with a heart failure specialist and consideration for advanced therapies, like transplant, should be initiated.

Contrast Tuned Imaging for Detection of Left Ventricular apical thrombus: A Case Report

Thrombi represent the most frequently found intracardiac masses. Left ventricular thrombus (LVT) is an important complication in patients with ischemic heart diseases and in those with dilated cardiomyopathy and systolic heart failure. The diagnosis of left ventricular thrombus remains important since anticoagulation will reduce the risk of systemic embolization and stroke. Despite advances in other imaging modalities, echocardiography remains the most important tool for diagnosis and risk stratification in patients predisposed to develop left ventricular thrombi. We are presenting a case report of 62 years old gentleman who had suffered from anterior wall myocardial infarction (AWMI) in the recent past, and now has developed LVT which was detected by contrast tuned imaging (CTI) technology based contrast echocardiography. This is a first case report of detection of LVT by this ingenious technology. Keywords: Thrombus, Left Ventricle, Ischemic Heart Disease, Anterior Wall Myocardial Infarction, Contrast Tuned Imaging, Left Ventricular Opacification.

Evaluation of the efficacy and safety of rivaroxaban compared to warfarin in patients with left ventricular apical thrombus: A randomized clinical trial

Evaluation of the efficacy and safety of rivaroxaban compared to warfarin in patients with left ventricular apical thrombus: A randomized clinical trial

Totally endoscopic trans-mitral removal of a left ventricular apical thrombus through right thoracotomy in a patient with subacute anterior myocardial infarction: a case report

BackgroundLeft ventricular thrombosis confers a life-threatening risk of systemic embolism; therefore, it requires prompt intervention. Although anticoagulation is the primary treatment, surgery is indicated in instances of large or/and mobile thrombus or when there is potential for recovery of ventricular contraction. However, standard left ventriculoplasty with thrombectomy carries risks of cardiac dysfunction due to left ventriculotomy.Case presentationA 70-year-old man developed chest pain and vomiting 3 weeks before presenting to our hospital. A chest radiograph showed substantial cardiomegaly and mild pulmonary congestion; N-terminal pro-brain natriuretic peptide (5698 ng/L) was substantially increased, and troponin T (56 ng/L) levels were slightly above reference values. Transthoracic echocardiography showed akinesis of the anteroseptal and apical segments with an ejection fraction reduced to approximately 20%. We diagnosed subacute myocardial infarction and initiated pharmacotherapy. On hospital day 7, coronary angiography revealed a left anterior descending artery lesion with 99% stenosis; percutaneous coronary intervention was successfully performed the next day. That same day, transthoracic echocardiography revealed a large mobile left ventricular apical thrombus without any left ventricular aneurysm, and heparin therapy was initiated. On hospital day 10, three-dimensional computed tomography confirmed the location of an apical thrombus, and we planned a fourth intercostal approach. A thrombectomy was performed on hospital day 11 using an endoscopic trans-mitral approach with a right thoracotomy to avoid a left ventriculotomy. The patient was discharged from intensive care on postoperative day 2 under heparin and warfarin therapy. The subsequent postoperative course was uneventful, and he was discharged on postoperative day 14 with a vitamin K antagonist. At the 6-month follow-up, there was no recurrence of thrombus in the left ventricle and Ejection Fraction had improved to 46%.ConclusionsTotally endoscopic thrombectomy via a trans-mitral approach through right thoracotomy was effective for a left ventricular thrombus. When concomitant coronary artery bypass grafting or left ventriculoplasty are not required, this procedure can be an effective option.

The Case Files

A patient presented after a cardiac cath with a football-sized mass in her groinFigure 1.: Axial CT angiography demonstrating right anterior thigh hematoma measuring 11.9 cm by 15.4 cm by 21 cm with active arterial extravasation (arrow).FigureFigureFigureA 56-year-old woman presented with shortness of breath and a cough she had had for a month. She also had associated orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion. A workup revealed an NSTEMI and new systolic heart failure, dilated cardiomyopathy (estimated ejection fraction 18%), and a sizable left ventricular apical thrombus on echocardiogram. Cardiac catheterization was performed and complicated by stable focal dissection of the right femoral artery and external iliac artery. She was discharged home on warfarin and enoxaparin for the LV thrombus. The patient returned to the ED one week later with symptoms of right groin pain and generalized lethargy, and she was in hypovolemic shock and had a massive right groin mass. Bedside ultrasound of the mass revealed a large hyperechoic fluid collection prompting resuscitation with two units of packed red blood cells to treat suspected hemorrhagic shock. She was also started on norepinephrine infusion for blood pressure and MAP support. Anticoagulation reversal was administered with 10 mg of vitamin K and one unit of FFP. CT angiography of the mass was obtained (Figures 1 and 2), and the patient was immediately taken to the OR for right femoral groin exploration for suspected right femoral artery injury with active arterial extravasation.Figure 2.: Coronal CT angiography demonstrating right anterior thigh hematoma with active arterial extravasation (arrow).Massive Hematoma The patient was diagnosed with post-catheterization femoral artery dissection with massive hematoma and active hemorrhage. She presented with hypotension, progressing to hypovolemic shock requiring aggressive fluid resuscitation, blood transfusion, vasopressors, and anticoagulation reversal. CT angiography showed a mixed density hematoma measuring 11.9 cm by 15.4 cm by 21 cm, and a small central focus of contrast blush. The patient was taken to the OR, where the surgeon found a hematoma the size of a football, which is roughly 17 cm in diameter and roughly 28 cm long. The hematoma was evacuated, and the femoral artery and external iliac arteries were repaired. Hematomas are the most common complication after cardiac catheterization. One review found that the incidence of femoral hematomas was 2.8 percent while active femoral and retroperitoneal bleeds were even lower at 0.6 percent and 0.3 percent, respectively. Dissection of the femoral or iliac arteries is also extremely rare, with an incidence of 0.46 percent. (Glob J Health Sci. 2012;4[1]:65; https://bit.ly/42TUAv5.) A large multicenter cohort study investigating vascular complications following endovascular cardiac procedures found that the incidence of major vascular complications was only 1.6 percent, defined as major hematoma (>10 cm), unstable bleeding, retroperitoneal hematoma, pseudoaneurysm, and arteriovenous fistula within a 48-hour periprocedural window. (Rev Lat Am Enfermagem. 2018;26:e3060; https://bit.ly/3lXFhRx.) The study also found that most vascular complications took place within six hours of surgery, making this patient's prolonged presentation even more unexpected. Most hematomas are self-limited, but larger ones with bleeding can cause hemodynamic instability. This patient was on anticoagulation for an LV thrombus, which likely complicated the bleeding. This case highlighted the importance of physician awareness of an emergent, rare presentation of a common hospital procedure—the cardiac cath. Clinical suspicion, especially in the periprocedural setting, rapid identification of the bleeding source, and immediate imaging make the diagnosis. Patients who continue to deteriorate despite resuscitative efforts require operative management. (StatPearls. Jan. 16, 2023; http://bit.ly/3nnkmaL.) Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

Three-dimensional transthoracic echocardiography successfully identified myocardial trabeculation mimicking left ventricular apical thrombus in a patient with COVID-19.

Three-dimensional transthoracic echocardiography successfully identified myocardial trabeculation mimicking left ventricular apical thrombus in a patient with COVID-19.

The relation between apical thrombus formation and systemic immune-inflammation index in patients with acute anterior myocardial infarction

Left ventricular (LV) apical thrombus formation is a well described and clinically important complication of acute myocardial infarction (MI) with a substantial risk of thromboembolism. Alterations in the inflammatory status may contribute to this complication. The aim of this study was to evaluate the predictive role of the systemic immune-inflammation index (SII) in identifying high risk patients who will develop an apical thrombus formation during the acute phase of anterior transmural infarction. Consecutive 1753 patients (mean age: 61.5 ± 9.6 years; male: 63.8 %) with first acute anterior MI who underwent primary percutaneous coronary intervention were assessed. Patients were divided into 2 groups according to the presence of apical thrombus. SII was calculated using the following equation: neutrophil (N) × platelet (P) ÷ lymphocyte (L). LV apical thrombus was detected on transthoracic echocardiogram in 99 patients (5.6%). Patients with an apical thrombus had lower LV ejection fraction, prolonged time from symptoms to treatment, higher rate of post-percutaneous coronary intervention thrombolysis in myocardial infarction flow ≤1 and significantly higher mean high-sensitivity C-reactive protein, and SII values and lower lymphocyte than those without an apical thrombus. Admission SII level was found to be a significant predictor for early LV apical thrombus formation complicating a first-ever anterior MI. This simple calculated tool may be used to identify high-risk patients for LV thrombus and individualization of targeted therapy.

Abstract 11157: A Rare Case of Concomitant Dual Genetic Cardiomyopathies in a Patient Complicated by Stroke

Background: Very little evidence exists on the prevalence of co-existing cardiomyopathies. We report in this case a highly atypical presentation of concurrent arrhythmogenic right ventricular cardiomyopathy (ARVC) and hypertrophic cardiomyopathy (HCM) likely attributable to simultaneous separate somatic mutations, complicated by stroke. Case: A 60-year-old male with a history of rheumatoid arthritis, sleep apnoea and obesity with no significant coronary disease referred for review of asymptomatic ECG abnormalities was found to have severe asymmetrical left ventricular (LV) wall thickening with apical segment akinesis and an LV apex mass on echocardiogram. She had a family history of early sudden cardiac death, with an otherwise unremarkable history and physical examination. Clinical Course: Cardiac MRI (CMR) subsequently demonstrated aneurysmal dilatation of LV apical segments with a 17x13mm thrombus present. Systolic anterior mitral leaflet motion was seen, and a dilated right ventricle (RV) with 240ml end-diastolic volume and 27% ejection fraction. "Accordion" sign was present in the sub-tricuspid RV free wall with dyskinesia, and ECGs confirmed presence of epsilon waves. One week after CMR, she suffered a large left middle cerebral artery (MCA) stroke in the setting of warfarin cessation due to echocardiography-suggestive absence of thrombus. Discussion: Genetic analysis revealed a mutated Plakophillin 2 (PKP2) gene, and FHOD3 gene associated with HCM of uncertain significance. The diagnosis was concomitant genetic cardiomyopathies of ARVC and HCM complicated by large LV apical aneurysm and thrombus culminating in left MCA stroke. PKP2 mutations to date have not been associated with hypertrophic phenotypes. This case therefore demonstrates the unlikely 1 in 2,500 incidence of coexistence of two separate cardiomyopathies likely attributable to simultaneous separate somatic mutations, while also highlighting the central role of CMR in investigation and diagnosis of RV pathology. In addition to this case, prior studies have also shown echocardiography can only identify 50% of ARVC cases identified by CMR, suggesting that selective use of CMR may double the number of identified cases of this life-threatening disease.

Abstract 12026: A Case of Eosinophilic Endomyocarditis in a Patient With Eosinophilic Leukemia and Hypereosinophilic Syndrome

Background: Eosinophilic (Loeffler’s) endomyocarditis is a restrictive cardiomyopathy caused by eosinophilic infiltration of myocardial. Complications include arrhythmias, intraventricular thrombus formation, and acute heart failure. Clinical Presentation A 37-year-old man with no past medical history presented with two weeks of fatigue and exertional dyspnea. He was found to have acute eosinophilic leukemia with a total white blood cell count of 440 k/mm^3 with 14% myelocytes, hypereosinophilic syndrome with an absolute eosinophil count of 56 k/mm^3, severe anemia and thrombocytopenia. Bone marrow biopsy and peripheral blood FISH analysis confirmed eosinophilic leukemia. He subsequently underwent leukopheresis, followed by treatment with hydroxyurea and imatinib. Cardiac Evaluation Echocardiogram revealed endomyocardial thickening of the left ventricular apex (Figure 1A). Cardiac MRI revealed left ventricular apical subendocardial wall thickness of 16 mm with subendocardial late gadolinium enhancement consistent with endomyocardial fibrosis (Figure 1B). The average global T1 value was 1100 ms and the calculated extracellular volume was 35%. MRI also revealed an apical left ventricular thrombus. The patient was treated with pulse dose of steroids in addition to the cancer-specific regimen. He did not initially receive anticoagulation due to severe anemia and thrombocytopenia. Subsequent echocardiography after three months of treatment revealed complete resolution of endomyocardial thickening and no evidence of a left ventricular thrombus. He had resolution of peripheral leukocytosis, hypereosinophilia, anemia, and thrombocytopenia. Conclusion This case presents the diagnosis and multidisciplinary management of eosinophilic endomyocarditis related to eosinophilic leukemia. Complete clinical and echocardiographic resolution was achieve following treatment with pulse-dose steroids and a cancer-specific regimen.

Abstract 10178: Concurrent Left Ventricular and Left Anterior Coronary Artery Thrombus; Is Covid-19 an Innocent Bystander?

Case presentation: A 36-year-old male was admitted to a local hospital with respiratory failure secondary to COVID-19 pneumonia. Initial management included oxygen, dexamethasone and baricitinib. On day 14 of illness the patient developed severe chest pain associated with widespread dynamic ST segment elevation and an elevated high sensitivity troponin I (17516 ng/L). He was transferred to a tertiary center for cardiac evaluation. Cardiovascular risk factors included treated hypertension and obesity (BMI 34). Physical exam revealed a blood pressure of 145/95 mmHg, regular heart rate at 90 bpm and coarse crepitations in bilateral lower lungs with a 3L oxygen requirement. Differentials included myopericarditis however, clinical suspicion for an acute coronary syndrome remained high. Urgent coronary angiogram revealed a large filling defect (figure 1A) at the mid-vessel of the LAD at the 1st diagonal bifurcation, likely a thrombus. Dual antiplatelet therapy, heparin and tirofiban infusion were commenced. Furthermore, echocardiography performed the same day revealed a reduced LVEF secondary to LAD territory hypokinesis and an associated apical left ventricular thrombus measuring 2.2x1.3 cm (figure 1B). Once established on anticoagulation the patient experienced no further chest pain and was discharged home on warfarin.The left ventricular thrombus was monitored for resolution in the community with serial transthoracic echocardiograms. Discussion: Raised highly sensitive troponin in the vicinity of severe COVID-19 infection is common, however, when associated with chest pain and or dynamic ECG changes myocarditis must be considered. The cytokine storm triggered by a SARS-CoV-2 infection can be thrombogenic, resulting from increased platelet activation and decreased fibrinolysis. This process may further complicate the evaluation and acute coronary syndrome does need consideration, even in those patients at a younger age with minimal risk factors.

A Starry Myocardium at CT: Cardiac Cysticercosis.

Supplemental material is available for this article.

Cognitive and Speech Rehabilitation in a Patient Affected by Takotsubo Cardiomyophathy: A Case Report

Background and Objectives: Takotsubo Syndrome (TS) constitutes one of the most recent clinical realities in modern cardiology. It is clinically similar to the acute coronary syndrome, in the absence of obstructive coronary artery disease. Case Presentation: We described a case of a female patient affected by TS and left ventricular apical thrombus. Several studies described the cardiological syndrome, overlooking the neuropsychological and psychological outcomes. We aimed to assess the advantages of an integrated, multidisciplinary and multifunctional rehabilitation. Conclusions: This specific training contributed to reducing the tolerance to frustration given by her communication’s difficulty. It has favored a good therapeutic alliance and a good success of the psychotherapeutic path, guaranteeing the reduction of her anxious symptoms and an improvement in the emotive and relational status.

The association between whole blood viscosity and high thrombus burden in patients with non-ST elevation myocardial infarction.

Prior studies showed that patients with elevated whole blood viscosity (WBV) had a higher risk of arterial thrombosis, acute stent thrombosis, and left ventricular apical thrombus presence after acute coronary syndrome. This investigation aimed to determine the association between WBV and high thrombus burden (HTB) in non-ST elevation myocardial infarction (NSTEMI) patients treated with percutaneous coronary intervention (PCI). This retrospective cohort investigation included data from consecutive 290 NSTEMI patients who received PCI at a tertiary institution. Patients with grade 1-3 thrombus burden were categorized as having low thrombus burden (LTB) (n = 178), whereas those with grade 4-5 thrombus burden were classified as having HTB (n = 112). WBV at high shear rate (HSR) and low shear rate (LSR) were estimated using hematocrit (HTC) and total protein levels. Patients with HTB had higher WBV at both LSR and HSR. In HTB patients, the frequency of infarct-related artery (IRA) reference vessel diameter, distal embolization, and no-reflow was also higher. Multivariable logistic regression models indicated that WBV at LSR (odds ratio [OR], 1.028; 95% confidence interval [CI], 1.014-1.043; P < 0.001) and HSR (OR, 1.606; 95% CI, 1.334-1.953; P < 0.001) were independent predictors of HTB in NSTEMI patients. Notably, the area under the curve value of WBV at both shear rates was greater than that of its components, including total protein and HTC. This is the first study showing that WBV at both shear rates is a significant predictor of HTB in NSTEMI patients.

Myocardial Infarction after ChAdOx1 nCoV-19 in a Young Male.

Sir, Myocardial infarction rarely happens in young age.[1] Hereby, we report the case of a 21-year-old patient who presented with myocardial infarction 14 days after receiving the ChAdOx1 nCoV-19 COVID-19 (AstraZeneca/Vaxzevria) vaccine. Sometimes thrombotic events associated with thrombocytopenia after immunisation occurs known as vaccine-induced immune thrombotic thrombocytopenia (VITT) which manifests 3–30 days post vaccination. Thrombocytopenia, raised Platelet factor-4 antibodies, increased d-dimer, thrombi are common findings in VITT.[23] Possible etiological factors such as hyperhomocystenemia, vegetation, autoimmune, nephrotic syndrome, obesity, metabolic syndrome, stress, hypercoagulability, comorbidities were evaluated and excluded.[4] The presentation here is chest pain radiating to arms and vomiting for 5 days. He received vaccination 14 days prior to symptoms. The patient has no history of smoking, alcohol, and substance abuse. Electrocardiogram showing ST elevation Anterior wall Myocardial infarction [Figure 1a]. Echocardiography showed akinetic anterior and lateral wall, left ventricular apical thrombus, severe left ventricular dysfunction, regional wall motion abnormality present, dilated left atrium, left ventricle, left ventricular ejection fraction-35%, grade 1 diastolic dysfunction. Biochemical parameters reveal elevated cardiac markers troponin I 96000 pg/ml, antinuclear antibody-0.11, homocysteine 14.5micromol/l, HbA1C-5%. Patient was treated with anticoagulants, dual antiplatelets, statins, beta blockers, ACE inhibitors, antianginals and diuretics. Coronary angiography revealed occluded mid left anterior descending artery and proximal diagonal artery [Figure 1b]. Later reperfusion was achieved through percutaneous transluminal coronary angioplasty by placing three stents.Figure 1: (a) ECG suggestive of ST elevation in lead 1, aVL, V1-V6, pathological q-waves in V1-V6, poor R-wave progression, QRS > 0.12 s in V1, V2, tall R-wave in V1, wide S-wave in L1, V5, V6, suggestive of acute anterior wall and (b) coronary angiographyIt is the onus of responsibility for dispelling erroneous or exaggerated reports of COVID-19 vaccination dangers. Further research study could be vital. It is commonly acknowledged that vaccination benefits outweigh the risks and must be mindful to link negative outcomes to vaccine, anticipate patient queries and findings should not be overstated. Declaration of patient consent We certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Research quality and ethics statement We followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Alcohol-Induced Cardiomyopathy Presenting with Left Ventricular Apical Thrombus

Alcohol-Induced Cardiomyopathy Presenting with Left Ventricular Apical Thrombus

Novel oral anticoagulant in treatment of left ventricular thrombus in acute coronary syndrome – A case series

Introduction: Left ventricular (LV) thrombus is a known complication of myocardial infarction (MI) and it usually occurs in areas of poorly contracting LV muscle as a result of endocardial injury with associated inflammation. There is a high risk of embolization within 3 months among patients with MI complicated by mural thrombus and this risk is maximum during the first 1–2 weeks. We report a case series of five patients who presented with acute coronary syndrome with LV apical thrombus and treated with triple anti-thrombotic therapy of rivaroxaban, aspirin, and clopidogrel. Case Series: Our series involves 5 cases who developed LV apical thrombus after acute coronary syndrome. Four patients had anterior wall ST-elevation MI (STEMI) whereas 1 patient had inferior wall STEMI. One of the patients with anterior STEMI also had COVID pneumonitis. All of these patients received triple anti-thrombotic therapy consisting of tab Aspirin 75 mg OD, tab clopidogrel 75 mg OD, and tab rivaroxaban 20 mg OD for 3 months duration. Repeat ECHO after 3 months showed complete resolution of LV thrombus in all of our cases. Discussion: LV thrombus reported in STEMI patients is from 1.6% up to 39% in various studies. The incidence of LV thrombus is on decreasing trend as a result of modern revascularization strategies. The role of novel oral anticoagulants (NOACs) in treating LV thrombus is scant as compared to oral Vitamin K antagonists (VKAs) like warfarin. The current recommendation for anticoagulation in the presence of a LV thrombus after acute coronary syndrome is with VKAs for up to 6 months. Conclusion: Although there is uncertainty in decision-making regarding antithrombotic therapy, our case series demonstrate that triple antithrombotic therapy with NOACs results in resolution of LV thrombus without any additional bleeding events in patients presenting with acute coronary syndrome. NOACs have an advantage of not requiring PT/INR monitoring and have less bleeding complications. Further large-scale research or randomized controlled trials are needed to find the optimal therapies in such cases.

A case of left ventricular apical thrombus extending into left ventricular outflow tract and role of intraoperative transesophageal echocardiography

A case of left ventricular apical thrombus extending into left ventricular outflow tract and role of intraoperative transesophageal echocardiography