Left Ventricular Thrombus In Patients Research Articles

New left ventricular thrombus and embolic events in left ventricular dysfunction postmyocardial infarction

Background: We aimed to assess the incidence and evolution of new left ventricular thrombus (LVT), and the incidence of manifest systemic embolism, in patients with severe left ventricular (LV) systolic dysfunction postacute anterior myocardial infarction (MI) who had been discharged on dual antiplatelet therapy. Methods: We prospectively included consecutive patients with postacute anterior MI and LV ejection fraction (LVEF) ≤35% or apical aneurysms or large infarctions with LVEF ≤40%. Transthoracic echocardiography (TTE) confirmed no LVT before hospital discharge, and a second TTE was performed at 30 days and a third one at 3 months. All TTE studies were prespecified to assess LVT, and the patients were screened for the development of clinically manifest systemic embolisms. Results: Two hundred and two consecutive patients (males 93%; mean age 55.2±6.4 years; mean LVEF 29.5±5.0%) were included. At 30 days (interquartile range: 2837 days), a new LVT was detected in 12 (5.9%) patients. Oral anticoagulant was added to all patients with LVT, and aspirin was continued in 5 (42.7%) patients for a month. The 3month TTE showed favorable evolution of LV size, LVEF and apical wall motion score index compared to the baseline. At 3 months, the LVT disappeared in 7 (58.3%) patients and 5 patients still had a mural LVT of smaller size, and none got new LVT. Among the group without LVT, one patient had a stroke, and another had a myocardial infarction and died. Conclusions: In contemporary practice, and using routine TTE, the incidence of new LVT in patients with severe LV dysfunction postacute anterior MI is low. They have a favorable LVT evolution with minor risk for clinically manifest systemic embolism.

Analysis factors influencing left ventricular thrombus in patients with non-ischemic heart failure

Objective: To explore the influencing factors of left ventricular thrombus (LVT) in patients with non-ischemic heart failure (NIHF) and to construct a nomogram prediction model for NIHF patients with LVT. Methods: This study was a case-control study. A total of 2 592 patients with NIHF hospitalized in Beijing Anzhen Hospital affiliated to Capital Medical University from January 2018 to July 2022 were selected. Fifty-one patients with LVT identified by echocardiography and cardiac magnetic resonance were classified into LVT group. One hundred and sixty patients were selected as the non-LVT group using a 1∶3 propensity score matching based on age and gender. Multivariate logistic regression analysis was used to explore the influencing factors of LVT in patients with NIHF. A nomogram prediction model was constructed, and the area under (AUC) the receiver operating characteristic (ROC) curve was calculated to evaluate the predictive effect of the model. Results: A total of 211 patients were enrolled, with a median age of 40 years old and 160 males (76%). Compared with non-LVT group, LVT group had lower systolic blood pressure ((112±20) mmHg vs. (120±19) mmHg; 1 mmHg=0.133 kPa), lower left ventricular ejection fraction (LVEF; (27±12)% vs. (39±14)% ), lower proportion of patients with history of hypertension (28% (14/51) vs. 44% (70/160)) and atrial fibrillation (8% (4/51)vs.39% (62/160)), higher proportion of patients with New York Heart Association functional class Ⅲ to Ⅳ (class Ⅲ: 59% (30/51) vs. 41% (66/160); class Ⅳ: 28% (14/51) vs. 19% (31/160)), and larger left ventricular end-systolic diameter (LVESD; (56±14) mm vs. (50±15) mm). The levels of hemoglobin ((152±23) g/L vs. (142±30) g/L), D-dimer (508 (300, 1 105) μg/L vs. 158 (68, 379) μg/L), and N-terminal pro-brain natriuretic peptide (3 429 (2 462, 4 734) ng/L vs. 1 288 (422, 2 544) ng/L) were higher in LVT group than in non-LVT group (P all<0.05). LVT group had a higher proportion of patients using beta-blockers (92% (47/51) vs. 78% (124/160)), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers or angiotensin receptor neprilysin inhibitors (88% (45/51) vs. 72% (115/160)), and anticoagulant drugs (98% (50/51) vs. 32% (51/160)) than non-LVT group (all P <0.05). Multivariate logistic regression showed that reduced LVEF (OR=1.08, 95%CI 1.02-1.15, P=0.008), decreased LVESD (OR=1.07, 95%CI 1.01-1.12, P=0.013), and increased D-dimer levels (OR=5.40, 95%CI 1.98-14.74, P=0.001) were independent influencing factors for LVT in patients with NIHF. The ROC curve showed that the AUC of the nomogram for predicting LVT in patients with NIHF was 0.793 (95%CI 0.710-0.876, P<0.001). Conclusion: Reduced LVEF, decreased LVESD, and elevated D-dimer are associated with LVT in NIHF patients. The predictive model developed based on the above indicators has certain value in predicting LVT in NIHF patients.

A New Nomogram Prediction Model for Left Ventricular Thrombus in Patients with Left Ventricular Aneurysm after Acute Myocardial Infarction.

To identify the factors influencing the development of a left ventricular thrombus (LVT) in patients with a left ventricular aneurysm (LVA) after acute myocardial infarction (AMI) and to utilize these variables to establish a new nomogram prediction model for individual assessment in LVT. We screened data on 1268 cases of LVA at the China-Japan Union Hospital of Jilin University between January 1, 2018 and December 31, 2023, and identified a total of 163 LVAs after AMI. The independent risk factors of LVT in patients with LVA after AMI were identified from univariable and multivariable logistic regression analyses and a nomogram prediction model of LVT was established with independent risk factors as predictors. We used the area under the curve (AUC) and a calibration curve to determine the predictive accuracy and discriminability of nomograms. Furthermore, decision curve analysis (DCA) was utilized to further validate the clinical effectiveness of the nomogram. Multivariate logistic regression analysis identified that preoperative thrombus in myocardial infarction 0, left ventricular diameter, and anterior wall myocardial infarction were independent risk factors of LVT in patients with LVA after AMI (p < 0.05). The nomogram prediction model constructed using these variables demonstrates exceptional performance, as evidenced by well-calibrated plots, favorable results from DCA, and the AUC of receiver operating characteristic (ROC) analysis was 0.792 (95% CI: 0.710-0.874, p < 0.01). A new nomogram prediction model was developed to enable precise estimation of the probability of LVT in patients with LVA after AMI, thereby facilitating personalized clinical decision-making for future practice.

Association between cardiac magnetic resonance ventricular strain and left ventricular thrombus in patients with ST-segment elevation myocardial infarction.

Myocardial strain can analyze early myocardial dysfunction after myocardial infarction (MI). However, the correlation between left ventricular (LV) strain (including regional and global strain) obtained by cardiac magnetic resonance (CMR) imaging and left ventricular thrombus (LVT) after ST-segment elevation myocardial infarction (STEMI) is unclear. The retrospective clinical observation study included patients with LVT (n = 20) and non-LVT (n = 195) who underwent CMR within two weeks after STEMI. CMR images were analyzed using CVI 42 (Circle Cardiovascular Imaging, Canada) to obtain LV strain values. Logistic regression analysis identified risk factors for LVT among baseline characteristics, CMR ventricular strain, and left ventricular ejection fraction (LVEF). Considering potential correlations between strains, the ability of LV strain to identify LVT was evaluated using 9 distinct models. Receiver operating characteristic curves were generated with GraphPad Prism, and the area under the curve (AUC) of LVEF, apical longitudinal strain (LS), and circumferential strain (CS) was calculated to determine their capacity to distinguish LVT. Among 215 patients, 9.3% developed LVT, with a 14.5% incidence in those with anterior MI. Univariate regression indicated associations of LAD infarct-related artery, lower NT-proBNP, lower LVEF, and reduced global, midventricular, and apical strain with LVT. Further multivariable regression analysis showed that apical LS, LVEF and NT-proBNP were still independently related to LVT (Apical LS: OR = 1.14, 95%CI (1.01, 1.30), P = 0.042; LVEF: OR = 0.91, 95%CI (0.85, 0.97), P = 0.005; NT-proBNP: OR = 2.35, 95%CI (1.04, 5.31) ). Reduced apical LS on CMR is independently associated with LVT after STEMI.

Clinical characteristics and outcomes of left ventricular thrombus patients with mildly reduced and preserved left ventricular ejection fraction

Abstract Background Abnormal left ventricular ejection fraction (LVEF) is associated with the development of left ventricular thrombus (LVT) following acute myocardial infarction and also in non-ischaemic cardiomyopathies. LVT formation in normal LVEF is less common. Purpose We aimed to describe the clinical characteristics and outcomes of patients with LVT and LVEF&amp;gt;40%, and compare them against patients with LVT associated with LVEF≤40%. Methods We retrospectively studied 551 consecutive patients with LVT from our tertiary centre’s echocardiography database between March 2011 and January 2021. We compared baseline co-morbidities and echocardiographic parameters between patients with LVT and LVEF&amp;gt;40% versus LVEF≤40%. The Kaplan Meier method with log-rank test was used to compare rates of thrombus resolution, stroke and all-cause mortality between the 2 groups. Multivariable Cox regression models were constructed to correct for potential confounders. Results Mean age of the study population was 59.8 ± 12.9 years old and 86/551 (15.6%) were female. LVT in patients with LVEF&amp;gt;40% made up 100/551 cases (18.1%), of which 91.0% were associated with ischaemic heart disease. Patients with LVEF&amp;gt;40% were younger and had fewer cardiovascular co-morbidities than their counterparts with LVEF≤40%, including a lower prevalence of hypertension, hyperlipidaemia, diabetes mellitus, ischaemic heart disease and heart failure (Figure 1). Patients with LVEF&amp;gt;40% more often had a smaller thrombus (mean diameter 14.1 ± 5.9 mm) compared to those with LVEF≤40% (mean diameter 17.2 ± 8.2 mm). LVT with LVEF&amp;gt;40% was independently associated with thrombus resolution (HR 1.42, 95% CI 1.08–1.87, p=0.013) corrected for anticoagulant use, as well as lower mortality (HR 0.49, 95% CI 0.26–0.94, p=0.031) corrected for baseline co-morbidities (Figure 2). LVEF did not influence stroke rates. Conclusions In patients with LVEF&amp;gt;40%, LVT was less common. These patients had fewer cardiovascular co-morbidities, developed smaller thrombi, were more likely to have thrombus resolution and had a lower mortality rate. However, overall stroke risk was similar to patients with a reduced LVEF.Figure 1:Baseline characteristicsFigure 2:Outcomes

Left ventricular thrombus in patients with heart failure with improved ejection fraction

Abstract Background This study sought to: (1) determine the prevalence of LV thrombus at baseline and at the time of recovered ejection fraction (EF) in patients with heart failure with improved ejection fraction (HF-imp EF), (2) examine clinical and echocardiographic factors associated with the presence of LV thrombus, and (3) determine the prevalence of thromboembolic events when LVEF was improved and oral anticoagulant (OAC) was discontinued. Methods and results Patients with nonischemic HF-imp EF defined as a baseline LVEF of ≤ 40%, a ≥ 10% increase from baseline LVEF, and a second measurement (6 months apart) of LVEF of &amp;gt; 40% were consecutively enrolled in advanced HF clinic in a tertiary center. Patients with recent myocarditis, recent coronary revascularization, active chemotherapy, hypertrophic cardiomyopathy, cardiac amyloidosis, and tachycardia induced cardiomyopathy were excluded. A total of 104 consecutive patients (age 51 ± 15 years; 66% were male) with HF-imp EF were included. Of these, 14 patients (14%) had LV thrombus at baseline. Baseline LVEDD, LVEF, and LV global longitudinal strain (GLS) were 61 ± 10 mm, 23 ± 15%, and -5.9 ± 3.3%, respectively. Younger age, absence of atrial fibrillation, receiving oral diuretics, lower LVEF, reduced LV GLS, and reduced RV free wall (FW) GLS were significantly associated with LV thrombus at baseline (p &amp;lt; 0.05 for all) (Table 1). All patients (100%) with LV thrombus at baseline received oral anticoagulants (OAC). At the median follow-up of 27 months, 14 (100%) had complete resolution of LV thrombus when LVEF &amp;gt; 40%. Of 14 patients, 11 (79%) who were in sinus rhythm discontinued OAC. After a median further follow-up of 27.4 months following OAC discontinuation, there was no thromboembolic event or all-cause mortality in these patients. One of 11 patients developed worsening LVEF and recurrent LV thrombus at 25 months after LVEF improvement (&amp;gt; 40%). Conclusions Approximately 1 in 6 patients with HF-imp EF had LV thrombus at baseline. LV thrombus formation was associated with more impaired LV and RV systolic function and myocardial deformation implicating more thromboembolic milieu. Complete resolution of LV thrombus occurred in all patients who were on OAC therapy at the time of imp-EF. Discontinuation of OAC when LVEF &amp;gt; 40% was safe. However, recurrent thrombus formation can occur when LV systolic function was deteriorated. Annual or bi-annual echocardiographic follow-up may be essential in these patients.

Abstract 13589: Prophylactic Anticoagulation to Prevent Left Ventricular Thrombus Following Myocardial Infarction: A Systematic Review and Meta-Analysis

Introduction: Left ventricular thrombus (LVT) complicates an estimated 12% of anterior STEMI. The current standard of care for STEMI patients includes primary PCI and dual antiplatelet therapy (DAPT). Guidelines from the American Heart Association recommend consideration of prophylactic anticoagulation to prevent LVT in select high-risk patients following STEMI. These guidelines have a low certainty of evidence (level C), with most studies published prior to the current era of primary PCI and DAPT. Therefore, an updated review is needed in this area. Methods: Electronic databases, including EMBASE, MEDLINE and CENTRAL were systematically searched from January 2012 to June 2022. We included primary studies that used PCI as the lone revascularization strategy for STEMI. Studies were included if they compared the incidence of LVT in patients receiving prophylactic anticoagulation and DAPT with those receiving DAPT alone. Results: 7,378 studies were screened, with 4 studies eventually included in this review. One study was a randomized control trial and three were retrospective cohort studies. Pooled analysis using a fixed-effects model showed LVT was significantly less common in the triple therapy (TT) group compared to the DAPT group (OR = 0.38; 95% CI = 0.17-0.86; p = 0.02). However, using a random-effects model, there was no significant difference in LVT between the TT and DAPT group (OR = 0.42; 95% CI = 0.04-4.67; p = 0.33). Conclusions: Based on the current state of knowledge, there is no compelling evidence to either support or oppose prophylactic anticoagulation in STEMI. An appropriately powered clinical trial is warranted due to the need for more robust data in this area.

Safety and Efficacy of Direct Oral Anticoagulant in Addition to Antiplatelet Therapy After Acute Coronary Syndrome: A Systemic Review and Meta-analysis of 53,869 Patients

IntroductionSignificant progress has been made in the management of patients with acute coronary syndrome (ACS) during the past few decades. However, the role of direct oral anticoagulants (DOACs) in post-ACS prophylactic therapy remains unknown. This study aims to assess the efficacy and safety of DOACs plus antiplatelet treatment (APT) after ACS. MethodsA systematic literature search was conducted to identify randomized clinical trials comparing DOACs plus APT with APT alone after ACS. The primary efficacy end points were cardiovascular mortality, myocardial infarction, all-cause mortality, and stroke and systemic embolization (SSE). The primary safety end point was major bleeding. The random-effects model was used to calculate relative risk (RR) and corresponding 95% CIs. ResultsNine trials with a total of 53,869 patients were identified, with 33,011 (61.2%) in the DOACs plus APT group and 20,858 (38.8%) in the APT alone group. The use of DOACs did not decrease the risk of cardiovascular death (RR = 0.87; 95% CI, 0.75–1.01; P = 0.08; I2 = 0%) or myocardial infarction (RR = 0.90; 95% CI, 0.80–1.02; P = 0.10; I2 = 6%). However, the risk of SSE was significantly lower in patients who received DOACs plus APT compared with APT alone (RR = 0.67; 95% CI, 0.50–0.90; P = 0.008). Moreover, all-cause mortality was significantly lower in the DOACs plus APT group (RR = 0.83; 95% CI, 0.71–98; P = 0.03; I2 = 0%). However, the risk of major bleeding was significantly higher in patients treated with DOACs plus APT compared with APT alone (RR = 2.53; 95% CI, 1.96–3.26; P < 0.01; I2 = 0%), as was the risk of nonmajor bleeding (RR = 2.27; 95% CI, 1.51–3.41; P < 0.01). ImplicationsDOACs plus APT for the prevention of left ventricular thrombus in patients with ACS were associated with a lower risk of SSE and all-cause mortality but increased the risk of major and nonmajor bleeding. The benefits and risks of this approach should be weighed based on a patient's individual clinical characteristics.

Rationale and design of the direct oral anticoagulants for prevention of left ventricular thrombus after anterior acute myocardial infarction (APERITIF) trial

Anterior acute myocardial infarction (AMI) is associated with an increased risk of left ventricular (LV) thrombus formation. We hypothesized that adding low-dose oral rivaroxaban to the usual antiplatelet regimen would reduce the risk of LV thrombus in patients with large AMI. APERITIF is an investigator-initiated, multicenter randomized open-label, blinded end-point (PROBE) trial, nested in the ongoing "FRENCHIE" registry, a French multicenter prospective observational study, in which all consecutive patients admitted within 48 hours of symptom onset in a cardiac Intensive Care Unit (ICU) for AMI are included (NCT04050956). Among them, patients with anterior ST-elevation-myocardial infarction (STEMI) or very high-risk non- ST-elevation-myocardial infarction (NSTEMI) patients with involvement of the left anterior descending artery are randomized into 2 groups: Dual Antiplatelet Therapy (DAPT) alone or DAPT plus rivaroxaban 2.5mg twice daily for 4 weeks, started as soon as possible after completion of the initial percutaneous coronary intervention/angiography procedure. The primary endpoint is the presence of LV thrombus at 1 month, as detected by contrast enhanced CMR (CE-CMR). Secondary endpoints include LV thrombus dimension (greatest diameter), the rate of major bleedings and major cardiovascular events at 1 month. Based on estimated event rates, a sample size of 560 patients is needed to show superiority of DAPT plus rivaroxaban therapy versus DAPT alone, with 80% power. The APERITIF trial will determine whether, in patients with large AMIs, the use of rivaroxaban 2.5mg twice daily in addition to DAPT reduces LV thrombus formation, compared with DAPT alone. gov Identifier: NCT05077683.

Frequency of Left Ventricular Thrombus after Acute Anterior Wall Myocardial Infarction at Karachi

Background: The left ventricular problem is a prominent acute myocardial infarction (AMI) complication. It has been demonstrated that rapid reperfusion reduces mortality and improves left ventricular (LV) function. There is a dearth of information on left ventricular thrombus (LVT) in the current era of primary percutaneous coronary intervention (PPCI). Aim: To estimate the frequency of left ventricular thrombus in patients who have experienced an acute anterior wall myocardial infarction at Karachi's leading cardiac hospital. Study design: Cross-sectional study Place and duration of study: Department of Cardiology, National Institute of Cardiovascular Disease, Karachi from 1st July 2021 to 31st December 2021. Methodology: Three hundred and fifty five patients of both genders age between 40 and 80 years were diagnosed with acute anterior wall myocardial infarction and underwent purcutaneous coronary intervention were enrolled. Results: There were 286 (80.6%) males and 69 (19.4%) females. The mean age was 56.29±11.04 years. Two patients (6%) experienced in-hospital mortality, while 56 patients (15.8%) had left ventricular thrombus. Conclusion: Acute ST-elevation myocardial infarction frequently results in the development of left ventricular thrombus. Keywords: Myocardial infarction, Left ventricular thrombus, Frequency

Features of Cerebral Infarction Due to Left Ventricular Thrombus.

Objective Left ventricular (LV) thrombus is a rare condition in acute cerebral infarction. The prevalence and features of cerebral infarction with LV thrombus are unclear. We explored the features of cerebral infarction due to LV thrombus. Methods In this single-center retrospective study, we investigated consecutive patients with acute ischemic stroke admitted within seven days of the onset who had LV thrombus found by transthoracic echocardiography (TTE). First, we calculated the prevalence of LV thrombus in patients with cardioembolic stroke (CES). Second, we investigated the baseline characteristics, including the TTE findings and features of cerebral infarction due to LV thrombus. Results From June 2012 to January 2019, a total of 5,693 patients were enrolled. Of these, 1,408 (25%) patients were diagnosed with CES. Of these 1,408 patients with CES, 13 (0.9%) had LV thrombus indicated by TTE, with dilative cardiomyopathy, subacute myocardial infarction, and old myocardial infarction present in 1 (8%), 2 (15%), and 10 (77%), respectively. The ejection fraction (EF) was 48.9% (25.3-64.7%). The maximum longitudinal size of LV thrombus was 13.4 (0.97-38.1) mm, and there was no correlation between the size of the LV thrombus and the EF. Regarding the features of cerebrovascular infarction, major vessel occlusion was observed in 10 (77%) patients. Six (46%) patients were found to have good outcomes (modified Rankin Scale 0-2) at 90 days after the onset. Conclusion LV thrombus was seen in 0.9% of patients with CES. Many of the patients with LV thrombus had major vessel occlusion.

Risk factors and outcomes associated with Left Ventricular Thrombus in patients with Peripartum Cardiomyopathy: An insight from National Inpatient Sample Database

Background: We sought to assess the prevalence and impact of left ventricular thrombus (LVT) in patients with peripartum cardiomyopathy (PPCM). Methods: We performed a retrospective cohort study of all admissions with PPCM as the primary diagnosis from the Nationwide Inpatient Sample database over a 11-year period. Univariate analysis of all risk factors and outcomes and multivariable logistic regression analysis of certain variables were performed and represented as odds ratio (OR) with 95% confidence interval (CI). A p value of < 0.05 was considered statistically significant. Statistical analysis was performed using epiDisplay in ‘R’ studio. Results: In the time frame spanning 2005 -2014, 43,986 admissions with PPCM were found which included 43,534 without LVT and 452 patients with LVT. Black race was associated with a higher incidence of LV thrombus, (p value <0.001). Comorbidities more prevalent in the LVT group were smoking, drug abuse, pregnancy induced hypertension, diabetes with complications, valvular heart disease, connective tissue disorders, coagulopathy, anemia and depression. Adverse outcomes such as congestive heart failure, arrhythmias and stroke were higher in LVT group. Conversely, Caucasian race, obesity, preeclampsia (p <0.005) were higher in those without LVT. Mean length of stay (9 vs 5 days, p <0.001), in hospital mortality (3.32% vs 1.41%, p = 0.001) and mean hospitalization charges ($85,390 vs $48,033) were higher in those with LVT. However, on multivariate logistic regression, although stroke was higher in the LVT group (adjusted OR 5.51, 95% CI, 2.2, 13.81, 5.05, p 0.002), in-hospital mortality was not significantly different between the two groups (adjusted OR 1.17, 95% CI,0.32, 4.23, p = 0.817). Conclusion: Our study showed that PPCM patients with LV thrombus had worse outcomes with respect to stroke, length of stay and in hospital mortality. Higher prevalence in patients with black race, complicated diabetes, peripheral vascular disease, valvular disease, coagulopathy, smoking, drug abuse, depression and psychoses calls for special attention to such high-risk groups for aggressive risk factor modification.

Intra-Left Ventricular Hemodynamics Assessed with 4D Flow Magnetic Resonance Imaging in Patients with Left Ventricular Thrombus.

Left ventricular thrombus (LVT) has been identified to be crucial in patients with reduced ejection fraction (EF). Three-dimensional cine phase-contrast magnetic resonance imaging (4D flow MRI) can visualize the intra-LV vortex during diastole and quantify the maximum flow velocity (Vmax) at the apex. In this study, we investigated whether the change in the intra-LV vortex was associated with the presence of LVT in patients with cardiac disease.In total, 36 patients (63.5 ± 11.9 years, 28 men, 12/24 with/without LVT) with diffuse LV dysfunction underwent 4D flow MRI. The relative vortex area using streamline images and Vmax of blood flow toward the apex at the apical left ventricle were evaluated. The correlation between the relative vortex area and Vmax was assessed using Pearson's correlation coefficient. The ability to detect LVT was evaluated using the area under the curve (AUC) of the receiver operating characteristic.The relative vortex area was found to be smaller (27 ± 10% versus 45 ± 11%, P = 0.000026), whereas Vmax at the apical left ventricle was lower (19.1 ± 4.4 cm/second versus 27.4 ± 8.9 cm/second, P = 0.0006) in patients with LVT. Vmax at the apical left ventricle demonstrated significant correlations with the relative vortex area (r = 0.43, P = 0.01) and relative transverse length of the vortex (r = 0.45, P = 0.007). The AUC was 0.91 for the relative vortex area, whereas it was 0.80 for Vmax in the apical left ventricle.A smaller LV vortex and lower flow velocity at the LV apex were associated with LVT in patients with reduced EF.

Abstract 13708: Left Ventricular Thrombus in Patients With Takotsubo Cardiomyopathy in the US Veteran Affairs Healthcare System

Introduction: Takotsubo cardiomyopathy is characterized by significant transient left ventricular (LV) dysfunction that is not due to obstructive coronary artery disease. LV thrombus is a known complication of Takotsubo cardiomyopathy, but the outcomes of these patients are not well described in the literature. The aim of our study was to investigate the rates and outcomes of patients diagnosed with Takotsubo cardiomyopathy with LV thrombus in the Veteran Affairs (VA) system. Methods: We performed a retrospective study using chart review for patients diagnosed with Takotsubo cardiomyopathy between 2005 and 2018 in the VA national database. We included patients who met the Mayo Clinic diagnostic criteria for Takotsubo cardiomyopathy. We collected data for demographics, clinical course, and outcomes. Results: 320 patients (69% males) were included. Median age was 64 years, 20.3% were known to have coronary artery disease, 34.7% had Diabetes and 61.3% had hypertension. 96.8% of patients had Apical variant of Takotsubo cardiomyopathy. LV thrombus was diagnosed in 8.8% of patients, all of those patients had apical variant of Takotsubo cardiomyopathy. There were no significant differences in the mortality rates in the hospital (14.3% vs 7.4%, p=0.15) and at 30-day follow up (4.2% vs 1.9%, p=0.45) in patients who developed LV thrombus compared to patients who did not. For patients who developed LV thrombus, only 1 patient developed a stroke on 30-day follow up; that patient was on therapeutic doses of warfarin for anticoagulation at the time of the stroke. Conclusions: In patients diagnosed with Takotsubo cardiomyopathy with LV thrombus, there was no significant difference in mortality rates in the hospital or at 30 day follow up when compared to patients with no LV thrombus. Only one of those patients developed a stroke during follow up, suggesting that the embolic risk is low with appropriate treatment.

Abstract 13829: Association Between E-wave Propagation Index and Left Ventricular Thrombus Formation in Systolic Heart Failure

Background: The E-wave propagation index (EPI) is a measure of apical blood flow and has been proposed as a risk marker of left ventricular thrombus (LVT) formation. We sought to investigate the association between EPI and LVT in patients with heart failure with reduced ejection fraction (HFrEF). Methods: This was a retrospective cohort study of patients with HFrEF. Follow-up echocardiograms were investigated for development of LVT. EPI was measured at baseline investigation as the velocity time integral of the transmitral E-wave divided by the left ventricular length. Logistic regression was used to investigate the association between EPI and LVT. Multivariable adjustments were made for age, significant mitral regurgitation, apical aneurysm, prior myocardial infarction, and left ventricular ejection fraction (LVEF). Results: Of 785 patients, 24 (3%) developed LVT. Mean age was 66 years, 73% were men, and LVEF was 28%. Those who developed LVT had significantly lower EPI (1.12 vs. 1.36, p=0.02). EPI was significantly associated with LVT in univariable logistic regression (OR=1.16 (1.03-1.31), per 0.1 decrease) (figure). These findings were unchanged after multivariable adjustments (OR=1.15 (1.00-1.31), per 0.1 decrease). The EPI provided an area under the curve of 0.68 with an optimal cutoff of 1.2. This cutoff had a sensitivity of 75%, specificity of 60%, positive predictive value of 6%, and negative predictive value of 99%. A low EPI was associated with a more than 4-fold increased risk of LVT (OR=4.56 (1.79-11.62), p=0.001). Conclusion: Decreasing EPI is associated with a higher risk of LVT. While a low EPI poses a markedly increased risk of LVT, a high EPI may be used to rule out LVT.

Insights on the left ventricular thrombus in patients with ischemic dilated cardiomyopathy

BackgroundLeft ventricular thrombus (LVT) formation represents a common complication of dilated cardiomyopathy (DCM). LVT is usually underestimated with transthoracic echocardiography (TTE) while cardiac magnetic resonance imaging (CMRI) is promising as an alternative imaging modality for cardiac thrombus detection. The study aims to compare TTE and CMRI in their ability to detect LVT, also, to assess the clinical and imaging parameters to determine variables that may predispose for thrombus formation. The study population includes seventy-six patients with ischemic DCM. They were divided into 2 groups based on the presence of LVT as detected by delayed-enhancement CMRI (DE-CMRI) [Group A included 20 patients with a LVT and Group B included 56 patients without].ResultsAll of the current study population had ischemic DCM with left ventricular ejection fraction (LVEF) < 50%. DE-CMR detected thrombus in 20 cases of the studied population that represented group A. From group A, conventional TTE detected LVT only in 8 and cine-CMR detected 13 cases out of the out of 20 cases. The ejection fraction of the left ventricle as measured by functional CMRI was significantly lower in group A (P = 0.045). Interestingly, the myocardial scarring in group A was seen significantly more extensive than in group B (the P value is < 0.00001), paralleling the increased prevalence of thrombus.ConclusionsDE-CMRI provides superiority for the detection of LVT compared with standard TTE or cine-CMRI and the amount of myocardial scarring detected by DE-CMRI can be considered an independent marker for thrombus presence.

Anticoagulation for the treatment of left ventricular thrombus in patients with acute myocardial infarction and renal impairment.

Anticoagulation for the treatment of left ventricular thrombus in patients with acute myocardial infarction and renal impairment.

Echocardiographic risk factors of left ventricular thrombus in patients with acute anterior myocardial infarction.

AimsThis study aimed to identify echocardiographic determinants of left ventricular thrombus (LVT) formation after acute anterior myocardial infarction (MI).Methods and resultsThis case–control study comprised 55 acute anterior MI patients with LVT as cases and 55 acute anterior MI patients without LVT as controls, who were selected from a cohort of consecutive patients with ischemic heart failure in our hospital. The cases and controls were matched for age, sex, and left ventricular ejection fraction. LVT was detected by routine/contrast echocardiography or cardiac magnetic resonance imaging during the first 3 months following MI. Formation of apical aneurysm after MI was independently associated with LVT formation [72.0% vs. 43.5%, odds ratio (OR) = 5.06, 95% confidence interval (CI) 1.65–15.48, P = 0.005]. Echocardiographic risk factors associated with LVT formation included reduced mitral annular plane systolic excursion (<7 mm, OR = 4.69, 95% CI 1.84–11.95, P = 0.001), moderate–severe diastolic dysfunction (OR = 2.71, 95% CI 1.11–6.57, P = 0.028), and right ventricular (RV) dysfunction [reduced tricuspid annular plane systolic excursion < 17 mm (OR = 5.48, 95% CI 2.12–14.13, P < 0.001), reduced RV fractional area change < 0.35 (OR = 3.32, 95% CI 1.20–9.18, P = 0.021), and enlarged RV mid diameter (per 5 mm increase OR = 1.62, 95% CI 1.12–2.34, P = 0.010)]. Reduced tricuspid annular plane systolic excursion (<17 mm) significantly associated with increased risk of LVT in anterior MI patients (OR = 3.84, 95% CI 1.37–10.75, P = 0.010), especially in those patients without apical aneurysm (OR = 5.12, 95% CI 1.45–18.08, P = 0.011), independent of body mass index, hypertension, anaemia, mitral annular plane systolic excursion, and moderate–severe diastolic dysfunction.ConclusionsRight ventricular dysfunction as determined by reduced TAPSE or RV fractional area change is independently associated with LVT formation in acute anterior MI patients, especially in the setting of MI patients without the formation of an apical aneurysm. This study suggests that besides assessment of left ventricular abnormalities, assessment of concomitant RV dysfunction is of importance on risk stratification of LVT formation in patients with acute anterior MI.

Validity of echocardiography for detection of left ventricular thrombus with surgical validation in patients awaiting durable left ventricular assist device.

Unrecognized left ventricular thrombi (LVT) can have devastating clinical implications and precludes patients with end-stage heart failure from undergoing left ventricular assist device (LVAD) implantation without cardiopulmonary bypass assistance. We assessed the reliability of an echocardiogram to diagnose LVT in patients with end-stage heart disease who underwent LVAD implantation. A single-center retrospective study evaluated 232 consecutive adult patients requiring implantation of durable LVADs between 2005 and 2019. The validity of preoperative transthoracic echocardiogram (TTE) and intraoperative transesophageal echocardiogram (TEE) for diagnosing LVT was compared to direct inspection at the time of LVAD implantation. There were 232 patients that underwent LVAD implantation, with 226 patients (97%) receiving a preoperative TTE. Of those 226 patients, 32 patients (14%) received ultrasound enhancing agents (UEA). Intraoperative TEE images were available in 195 patients (84%). The sensitivity of TTE without UEA was 22% and specificity was 90% for detecting LVT, compared to 50% and 86%, respectively, for TTE with UEA. For intraoperative TEE, the sensitivity and specificity were 46% and 96%, respectively. The false omission rate ranged from 4% to 8% for all modalities of echocardiography. Among patients undergoing LVAD implantation, preoperative TTE and intraoperative TEE had poor sensitivity for LVT detection. Up to 8% of echocardiograms were incorrectly concluded to be negative for LVT on surgical validation. The low sensitivity and positive predictive value for diagnosing LVT suggest that echocardiography has limited reliability in this cohort of patients who are at high risk of LVT formation and its subsequent complications.

Related factors of left ventricular thrombus formation within two weeks in patients with acute ST-segment elevation myocardial infarction and left ventricular aneurysm

Objective: To investigate the related factors of left ventricular thrombus (LVT) formation within two weeks in patients with acute ST-segment elevation myocardial infarction (STEMI) and left ventricular aneurysm (LVA). Methods: Consecutive inpatients with acute STEMI and left ventricular aneurysm, hospitalized from January 2014 to June 2020 in the First Affiliated Hospital of Zhengzhou University, were enrolled in this retrospective study. Patients were divided into LVT group and non-LVT group according to the presence or absence of LVT. The clinical data, echocardiography findings, coronary angiography and treatments were compared between the two groups. Subgroup analysis was performed on the patients receiving primary percutaneous coronary intervention (PCI). Onset to door, door to balloon, onset to balloon time were also compared. Multivariate logistic regression was used to analyze the related factors of LVT formation early post STEMI in enrolled patients. The effects of each index in multivariate logistic regression analysis were illustrated in the forest plot. Results: A total of 144 patients were included, there were 52 cases (36.1%) in LVT group, the age was (56.4±11.2) years, and 46 (88.5%) cases were male. There were 92 cases (63.9%) in non-LVT group, the age was (61.7±11.5) years, and there were 73 (79.3%) males in this group. The patients in LVT group were younger than those in non-LVT group, the proportion of anemia, history of heavy drinking, history of chronic kidney disease, left ventricular ejection fraction (LVEF) ≤40%, preoperative thrombosis in myocardial infarction (TIMI) blood flow grade 0 and postoperative TIMI blood flow grade ≤2 were significantly higher in LVT group than those in non-LVT group (all P<0.05). The incidence of history of angina, collateral circulation of the coronary arteries, primary PCI or venous thrombolysis were significantly lower in LVT group than those in non-LVT group (all P<0.05). The percentage of anti-platelet therapy and anticoagulant therapy was similar between the two groups (all P˃0.05). Subgroup analysis in patients undergoing primary PCI showed that onset to door, door to balloon, onset to balloon time were similar between the two groups. Multivariate logistic regression analysis and forest plot showed that history of heavy drinking (OR=6.982, 95%CI 1.501-32.469, P=0.013), anemia (OR=3.373, 95%CI 1.075-10.585, P=0.037), LVEF≤40% (OR=3.016, 95%CI 1.027-8.859, P=0.045), preoperative TIMI blood flow grade 0 (OR=3.311, 95%CI 1.214-9.029, P=0.019) were positively correlated with LVT in patients with acute STEMI and LVA. History of angina (OR=0.159, 95%CI 0.058-0.441, P<0.001), collateral circulation of the coronary arteries (OR=0.189, 95%CI 0.053-0.673, P=0.010), primary PCI or venous thrombolysis (OR=0.252, 95%CI 0.093-0.682, P=0.007) were negatively correlated with LVT in patients with acute STEMI and LVA. Conclusions: History of heavy drinking, anemia, LVEF ≤40%, preoperative TIMI blood flow grade 0 are associated with increased risk of the LVT in patients with acute STEMI and LVA at early stage of the disease. However, history of angina, collateral circulation of the coronary arteries, primary PCI or venous thrombolysis are associated with lower risk of the LVT in these patients.