Left Ventricular Thrombus Research Articles

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.

Abstract 15929: Safety Profile of Ultrasound Enhancing Agents in Echocardiography Across Yale New Haven Health System

Background: Ultrasound Enhancing Agents (UEAs) are increasingly used in echocardiography for delineation of endocardial border and detection of left ventricular (LV) thrombus with reported rate of serious adverse reactions from 0 to 0.029%. Contemporary utilization and safety data of UEA in echocardiography are scarce. Aims: We aimed to obtain contemporary data on comparative safety of UEA Lumason and Definity in inpatient and outpatient settings across large academic healthcare system. Methods: A retrospective database analysis of all echocardiograms performed within Yale New Haven Health System (YNHHS) between January 1, 2019 to December 31, 2022 was done. Echocardiography reporting software captured type of UEA as well as any observed adverse reaction. All reported adverse events were manually chart reviewed through electronic medical record for confirmation and grading severity. American College of Radiology (ACR) criteria for contrast agent reaction were used for grading to mild, moderate, or severe reaction. Adverse reactions differences were analyzed with Pearson’s chi-square and predictors were identified by Logistic regression. Results: Out of 305,749 echocardiograms 91,215 (29.83%) required UEAs. In total, 430 (0.47%) adverse events were reported. Lumason (49216, 54.42%) and Definity (41077, 45.42%) were mainly used agents with 158 (0.32%) and 270 (0.66%) reactions recorded, respectively (p<0.001). There were more mild reactions with Definity (245, 0.6%) Vs Lumason (124, 0.25%) (p <0.001), and more severe reaction with Lumason (13, 0.026%) Vs Definity (3, 0.007%) (p=0.0322). Females had higher chance of having any form of contrast reaction (OR 1.707; 95% CI: 1.412-2.065). Older age (OR 0.984 per 1 year; p <0.0001) and higher heart rate (OR 0.993 per 1 bpm; P = 0.050) were associated with a decreased chance of reaction. Ejection fraction and body mass index were not associated with adverse events. Conclusion: UEAs are frequently used in routine echocardiography studies. Adverse reactions to UEA were rare and mostly mild. Severe reactions were more frequent with Lumason than Definity. Female sex, younger age and lower heart rate were associated with increased incidence of adverse reactions.

Abstract 17281: Outcome of Stress-Induced Cardiomyopathy in Patients With Covid-19 Infection: A US Cohort Propensity-Matched Study

Introduction: COVID-19 has affected millions of people worldwide and is associated with cardiovascular complications like myocarditis, MI, pericarditis & stress-induced cardiomyopathy (Takotsubo cardiomyopathy). Hypothesis and aim: The aim of our study was to examine the outcomes of stress-induced cardiomyopathy in patients with COVID-19. Methods: Using TriNetX, which aggregates >100 million patients' charts, we identified adults (>18) between Jan. 2020 & Apr. 2023. We identified 2 groups: stress induced cardiomyopathy in the setting of COVID-19, & stress-induced cardiomyopathy without COVID-19. We performed 1:1 propensity score matching for demographics and co-morbidities like DM, HTN, HLD, IHD, CKD, obesity, PVD, COPD, liver cirrhosis, smoking & alcohol abuse. We conducted Kaplan-Meier survival analysis to assess all-cause mortality. Adjusted odds ratios (aOR) with 95% confidence interval (CI) were calculated to express the risk of each outcome. Results: We identified 1990 cases of stress-induced cardiomyopathy with COVID-19, and 27,702 patients with stress-induced cardiomyopathy without COVID-19. The majority were female gender and white race across the groups. Table 1 summarizes the demographics and characteristics of cohorts. After matching, stress-induced cardiomyopathy with COVID-19 were more likely to develop LV thrombus (aOR 1.41 [1.02-1.61]), cerebral infarction (aOR 1.25 [1.05-1.47]), acute respiratory failure (aOR 1.72 [1.53-1.94]), cardiogenic shock (aOR 1.37 [1.09-1.72]), and VTE (aOR 1.86 [1.61-2.14]). No difference was found in VT (aOR 0.89 [0.72-1.10]), or cardiac arrest (aOR [1.13 (0.88-1.45]), figure 1. All cause-mortality was worse in COVID-19 associated stress-induced cardiomyopathy (HR 1.17 [1.007-1.35]). Conclusions: Stress induced cardiomyopathy in the setting of COVID-19 was associated with a higher risk of adverse events and increased mortality compared to stress induced cardiomyopathy without COVID-19.

Pedunculated left endoventricular thrombosis complicated by cerebral stroke in patient with suspected peripartum cardiomyopathy: A case report

Peripartum cardiomyopathy (PPMC) is an infrequent form of cardiomyopathy, whose main presentation is characterized by systolic dysfunction that commonly emerges in the early postpartum period. Acute heart failure symptoms such as congestion and dyspnea are common manifestations of PPMC. Here, we present a case of a 32-year-old female who, after hospitalization, manifested dyspnea and thoracic pain linked to the findings a left endoventricular thrombus. After the admission to the intensive cardiovascular care unit, heart failure and anticoagulant therapies as well as non-steroidal anti-inflammatory drugs were administered, leading to initial improvement of the left ventricular global function. Five days after the treatment, the patient experienced aphasia and right hemiplegia. The cerebral angiography documented an M1 segment occlusion. After treating the occlusion with stent retriever thrombectomy, the symptoms regressed and she attained full recovery. Therefore, surgical thrombectomy should be prioritized as the treatment approach to removing the pedunculated left ventricular thrombus, considering the apical morphology of the pedunculated left ventricular thrombus and if the anticoagulant therapy gives rise to side effects.

Right Ventricular Thrombus on Echocardiography

Right ventricular thrombi (RVTs) have been almost exclusively studied in patients with pulmonary embolism (PE). The implications of an isolated RVT, a finding typically encountered on transthoracic echocardiography (TTE), are lacking. In this study, we sought to identify the echocardiographic and clinical features associated with the presence of RVTs. Between 1998 and 2023, 138 patients with RVT documented on TTE were retrospectively identified. Demographic data, presence of intracardiac devices, hypercoagulable conditions, history of deep vein thrombosis (DVT), PE, and/or left ventricular thrombus were abstracted from electronic chart review. Measurements of right and left ventricular size, and function were performed on TTE. Of the total population of patients with RVT, <1/2 had intracardiac devices, 29% had a documented hypercoagulable state (e.g., cancer or a clotting disorder). Most patients had dilated (77%) and dysfunctional (72%) right ventricles. Approximately 50% of RVTs were discovered in nonstandard imaging planes, suggesting that the presence of RVT is likely underestimated in clinical practice. Of those evaluated for PE, 80% had PE. Of those evaluated for DVT, 53% had DVT. In conclusion, further investigations are warranted to better guide when to investigate the right ventricle for RVTs on TTE and the impact of RVTs on patient outcomes.

Direct oral anticoagulants (DOAC) versus vitamin K antagonist in left ventricular thrombus: An updated meta-analysis.

Current clinical guidelines for treating left ventricular thrombus (LVT) are limited by inadequate evidence to inform the comparative efficacy of oral anticoagulants. In this meta-analysis, we aimed to compare the efficacy and safety of direct oral anticoagulants (DOAC) to vitamin K antagonists (VKA) in patients with LVT. Four standard databases were searched for relevant literature comparing the efficacy and safety between DOAC and VKA for LVT treatment, published before August 19, 2023. Both the randomized controlled trials and observational studies were included in the analysis. The outcomes of interest were the resolution of LVT, all-cause mortality, stroke, systemic embolism, and bleeding. Data from the selected studies were extracted and analyzed using RevMan 5.4 using odds ratio. Among 3959 studies from the database search and bibliography review, 33 were included in the analysis. LVT resolution was observed in 72.59% in the DOAC group versus 67.49% in the VKA group (odds ratio [OR]: 1.28, confidence interval [CI]: 1.07-1.53). Mortality was lower in the DOAC group (11.71% vs. 18.56%) (OR: 0.60, CI: 0.36-1.00; borderline statistical significance). Likewise, bleeding events (9.60% vs. 13.19%) (OR: 0.65, CI: 0.52-0.81) and stroke (7.54% vs. 11.04%) (OR: 0.71, CI: 0.53-0.96) were also significantly lower in the DOAC group. DOAC use for LVT showed better thrombus resolution and reduced risk of bleeding and stroke compared to VKA. Likewise, DOAC use was associated with lower mortality with borderline statistical significance.

Sex Differences in the Clinical Outcomes of Patients With Takotsubo Stress Cardiomyopathy: A Meta-Analysis of Observational Studies

BackgroundThe incidence of takotsubo stress cardiomyopathy (TSCM) in males is low compared to females. Sex-based differences in clinical outcomes of TSCM are not well characterized. The aim of this meta-analysis was to analyze whether sex-based differences are observed in TSCM clinical outcomes. MethodA comprehensive literature search of Pubmed, Embase, Cochrane Library database, and Web of Science was performed from inception to June 20, 2022, for studies comparing the clinical outcomes between males versus females in TSCM. The primary outcome of interest was in-hospital all-cause mortality and cardiogenic shock. The secondary outcomes were cardiovascular mortality, receipt of mechanical ventilation, intra-aortic balloon pump, and occurrence of ventricular arrhythmia, and left ventricular thrombus. A random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CI). Heterogenicity was assessed using the Higgins I2 index. ResultsTwelve observational studies involving 51,213 patients (4,869 males, and 46,344 females) were included in the meta-analysis. Male sex was associated with statistically significant higher in-hospital all-cause mortality when compared to females in patients with TSCM (RR 2.17; 95% CI 1.77–2.67; P < 0.001) The rate of cardiogenic shock was significantly higher in males with TSCM as compared to females (RR 1.66; 95% CI 1.29-2.12; P < 0.001). ConclusionOur meta-analysis showed a difference in the clinical outcomes of TSCM between men and women. Males sex was associated with a two-fold greater in-hospital all-cause mortality risk compared to female sex. The higher mortality risk associated with male sex deserves further study, and particularly whether it represents later recognition of the condition and disparities in treatments.

CLINICAL SUSPICION OF LEFT VENTRICULAR APICAL THROMBUS - WHAT TO DO?: 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) based contrast echocardiography. This is a first case report of detection of LVT by this ingenious technology.

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.

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.

Time Trends of Etiology, Treatment, and Long-Term Outcomes Among Patients with Left Ventricular Thrombus.

Recommendations for drug treatment of left ventricular thrombus (LVT) are based on the ST-segment elevation myocardial infarction (STEMI) guidelines; however, the etiology of LVT has changed. Due to the lack of evidence regarding LVT treatment in the heart failure population, current heart failure guidelines do not cover LVT treatment. We sought to review the etiology of LVT and changes in antithrombotic therapy over the previous 12 years and explore the impact of anticoagulation treatment from a single center's experience. From January 2009 to June 2021, we studied 1675 patients with a discharge diagnosis of LVT at a single center to investigate the clinical characteristics, incidence of all-cause death, cardiovascular death, ischemic stroke, major adverse cardiac and cerebrovascular events (MACCE), systemic embolism (SE), and major bleeding events. Patients were divided into an anticoagulant group and a non-anticoagulant group according to whether they received oral anticoagulant therapy at discharge. The study included 909 patients (anticoagulation, 510; no anticoagulation, 399). While overall antiplatelet therapy dramatically decreased, more patients with LVT received oral anticoagulation in 2021 (74.0%) than in 2009 (29.6%). In addition, more than half of the patients had heart failure with reduced ejection fraction (HFrEF) each year. The all-cause mortality was 17.3% during 3.8 years of follow-up. The incidences of cardiovascular death, stroke, MACCE, SE, and major bleeding were 16.0%, 3.3%, 19.8%, 5.1%, and 1.7%, respectively. The anticoagulation group had a significantly higher proportion of dilated cardiomyopathy than the non-anticoagulation group (24.7% vs. 5.5%, p 0.001), and a lower LVEF (34.0 vs. 41.0, p 0.001). The anticoagulation group also had a higher probability of adverse events on long-term follow-up (p 0.05). A multivariable competing risk regression model found no significant difference in all six endpoints between the groups (all p 0.05). Similar results were found by matched and weighted data analysis. Diabetes mellitus (hazard ratio (HR), 1.42; 95% confidence interval (CI), 1.04-1.93; p = 0.027), renal insufficiency (HR, 2.36; 95% CI, 1.60-3.50; p 0.001), history of previous stroke (HR, 1.60; 95% CI, 1.13-2.29; p = 0.009), and HFrEF (HR, 2.54; 95% CI, 1.78-3.64; p 0.001) were predictors of increased risk of MACCE. Heart failure, rather than acute myocardial infarction, is currently the primary cause of LVT. A trend towards better prognosis in the no anticoagulation group was noted. Multivariable, matching and weighting analysis showed no improvement in prognosis with anticoagulant therapy. Our study does not negate the efficacy of anticoagulation but suggests the need to strengthen the management of anticoagulation in order to achieve better efficacy.

SYSTEMIC IMMUNE-INFLAMMATION INDEX IS A PREDICTOR OF LEFT VENTRICULAR THROMBUS FORMATION FOLLOWING ANTERIOR MYOCARDIAL INFARCTION

Introduction: Left ventricular thrombus (LVT) formation following anterior ST-elevation myocardial infarction (STEMI), is a serious complication and is associated with an increased risk of cardiovascular morbidity and mortality. Recently introduced the systemic immune-inflammation index (SII) is a reliable indicator of adverse events in various cardiovascular conditions. Herein, we aimed to explore the role of SII in the prediction of LVT formation in anterior STEMI patients following primary percutaneous coronary intervention (PCI). Methods: Medical records of 124 anterior STEMI patients who developed LVT following primary PCI and 124 age and sex-matched anterior STEMI patients without formation of LVT following primary PCI were analyzed. For each group, patient demographics, comorbidities, laboratory parameters, ECG and echocardiographic findings were analyzed. The SII was measured using the following formula: SII= total peripheral platelets count x neutrophil/lymphocyte ratio. Results: According to our study, reduced left ventricular ejection fraction and increased SII were identified as independent predictors of LVT formation following anterior STEMI. To determine the SII index cut-off value for predicting LVT formation, the ROC curve was drawn and the best cut-off value was determined as 676.27 (AUC:0.778, 95% CI:0.699-0.858, p&lt;0.001). Above this cut-off value, LVT formation could be predicted with a sensitivity of 66.1% and a specificity of 74.2%. Conclusion: SII is may be used as an independent predictor of LVT formation for anterior STEMI patients following primary PCI.

Percutaneous coronary intervention can be safely performed with left ventricular thrombus without increasing stroke risk: A 5-year retrospective review using real-world data

IntroductionLeft ventricular thrombus (LVT) increases the risk of ischemic stroke. However, it remains uncertain if the percutaneous coronary intervention (PCI) in the confirmed LVT setting further augments the stroke risk. Therefore, in this study, we evaluated the risk of stroke among patients with LVT undergoing CAG +/− PCI. MethodsThis retrospective observational cohort study included all the patients encountered with LVT from 1st of April 2015, to 31st of March 2020. The study population was divided into two groups: Longobardo et al. (2018) [1] patients with LVT who underwent CAG +/− PCI; Solheim et al. (2010) [2] patients with LVT who did not undergo CAG +/− PCI. The primary outcome evaluated was stroke during the index admission, and the secondary outcomes included in-hospital mortality, all-cause mortality, and stroke at 12 months post-discharge. Logistic regression was used to determine the risk of stroke associated with PCI among patients with LVT, and a p-value<0.05 indicated statistical significance. ResultsOf the 210 patients included, 119 underwent CAG +/− PCI, while 91 patients did not undergo CAG +/− PCI. Most of the patients were Asian (67%), male (96%), with a mean age of 56 years. Ischemic cardiomyopathy was the primary etiology of LVT in both groups (96% in the CAG +/− PCI group and 80% in non CAG +/− PCI group). During the index admission, stroke among patients with LVT did not differ between the CAG +/− PCI and non CAG +/− PCI groups (5% versus 3.3%; odds ratio (OR) 1.6, 95% confidence interval (CI) 0.34–6.4, p = 0.539; adjusted OR 0.9, 95% CI 0.09–10.6, p = 0.968). Similarly, in-hospital mortality, all-cause mortality, and stroke at 12 months did not differ between the study groups. ConclusionPerforming CAG +/− PCI among patients with LVT was not associated with an increased risk of stroke during admission or within 12 months in comparison to patients who did not undergo CAG +/− PCI, which may reassure cardiologists to perform CAG +/− PCI among patients with LVT safely.

FRI259 Antiphospholipid Syndrome And Adrenal Insufficiency: An Underrated Association

Abstract Disclosure: S. Khalid: None. M. Arumugam: None. P. Passarella: None. Introduction: Catastrophic Antiphospholipid Syndrome (CAPS) is a rare and life-threatening subtype of Antiphospholipid Syndrome (APS) that causes widespread vascular thrombi. Endocrine complications of APS are very rare, however the most common is Adrenal Insufficiency (AI). Overt AI is only found in 0.4% of patients with APS while only 0.5% of patients with AI are diagnosed with APS. Either thrombosis leading to infarction or hemorrhage can cause AI in patients with APS. Sometimes, adrenal insufficiency or crisis can be the primary presentation of APS. Here, we present a case of AI in the setting of CAPS. Case Presentation: A 17-year-old woman with past medical history of chronic immune thrombocytopenia was admitted to the intensive care unit due to cardiogenic and distributive shock. One week prior to her presentation she had developed a sore throat followed by progressive lethargy that eventually evolved into a state of unconsciousness and she was brought to the emergency department. Her presenting vital signs included temperature of 40.7 C and blood pressure of 89/36 mmHg. On physical exam, she appeared somnolent and pale, and had cool extremities. Labs on admission (11 pm) revealed cortisol level of 3.6 UG/DL (reference range 3.8-19.4 UG/DL), TSH 4.61 UIU/ml (reference range 0.45-4.5 UIU/ml), free T4 1.3 ng/dl (reference range 0.6-1.3 ng/dl), aldosterone 11.3 ng/dl (reference range supine &amp;lt; 3-39.2 ng/dl), sodium 135 MEQ/L (reference range 135-145 MEQ/L), and potassium 4.7 MEQ/L (reference range 3.5-5.2 MEQ/L). Echocardiogram was remarkable for new onset reduced ejection fraction of 25-30% and left ventricular thrombi. Additionally, brain MRI showed acute infarcts. Due to concern for an underlying rheumatological disease, extensive autoimmune work up was initiated, and she was started empirically on methylprednisolone 30 mg intravenous twice daily. To further evaluate thrombi, CT scan of the abdomen and pelvis was performed, revealing bilaterally enlarged and hypoenhancing adrenal glands likely related to ischemia or infarction along with left renal vein thrombosis. Laboratory work-up returned positive for anti-cardiolipin IgM and IgG antibodies. In the setting of multiple vascular thrombi and positive antibodies, she was diagnosed with CAPS. The diagnosis of AI was made due to a low cortisol level in a state of shock and was deemed secondary to CAPS. For the treatment of CAPS she was continued on methylprednisolone with a plan for a slow taper. To ensure mineralocorticoid replacement was adequate fludrocortisone was also added at a dose of 0.1 mg with close monitoring of electrolytes and vital signs. Conclusion: Our case illustrates a rare though potentially fatal endocrine complication of CAPS and highlights the importance of its awareness. Undiagnosed and untreated adrenal insufficiency can lead to extremely poor outcomes, including death. Presentation: Friday, June 16, 2023

A Meta-Analysis for the Efficacy and Safety of Direct Oral Anticoagulants versus Vitamin K Antagonists for Left Ventricular Thrombus

Objectives: The objective of this updated meta-analysis is to consolidate high-quality peer-reviewed clinical evidence, including trials and observational studies, to evaluate the efficacy and safety of “direct oral anticoagulants (DOACs)” versus “vitamin K antagonists (VKAs)” for treating “left ventricular thrombus (LVT)”. Methodology: We included studies of either "observational" or "experimental" in nature reported original data for the head-to-head comparison of "DOACs" and "VKAs" for the treatment of LVT. The efficacy-related outcome of interest was "thrombus resolution" and safety-related outcomes of interest were; "mortality", "major bleeding", and "stroke". The “risk ratios (RRs)” for each outcome variable were calculated using the “Mantel-Haenszel method”. Results: The analysis included 19 studies comprised of 3,027 patients diagnosed with LVT. Among them, 881 received DOAC treatment, while 2,146 were treated with VKAs. DOACs showed comparable rates of LVT resolution (RR: 1.00 [0.93 – 1.08]), lower mortality incidence (RR: 0.65 [0.51 – 0.84]), similar stroke incidence (RR: 0.83 [0.61 – 1.14]), and similar major bleeding incidence (RR: 0.71 [0.50 – 1.00]) compared to VKAs. Conclusion: The meta-analysis indicates that DOACs are as effective as VKAs for treating LVT, showing comparable thrombus resolution rates, lower all-cause mortality, similar stroke risks, and clinically relevant bleeding across studies. However, these conclusions are limited by the lack of evidence from large-scale randomized studies and high-quality real-life clinical data.

Left ventricular thrombosis with peripheral embolization in several vascular zones – clinical case

We present a clinical case of a 49-year-old man admitted in severe general condition and echocardiographic evidence of a thrombotic mass in the left ventricle. Due to a peripheral embolization clinic, catheter-directed thrombolysis (CDT) followed by anticoagulant therapy was performed. This resulted in lysis of the left ventricular thrombus and reperfusion of the emboli in the peripheral arteries. Due to residual occlusion of the left anterior tibial artery, amputation of the front part of the foot of the left lower limb was required. As a result of the treatment, stabilization of the patient&amp;rsquo;s condition and withdrawal of the amputation line as distal as possible was achieved. The patient had severe left ventricular systolic dysfunction and highgrade mitral regurgitation, necessitating discussion of further management.

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.

A systematic review and meta-analysis of transthoracic echocardiogram vs. cardiac magnetic resonance imaging for the detection of left ventricular thrombus.

Transthoracic echocardiography (TTE) is the most commonly used imaging modality to diagnose left ventricular thrombus (LVT), however, cardiac magnetic resonance (CMR) remains the gold standard investigation. A comparison of the diagnostic performance between two modalities is needed to inform guidelines on a diagnostic approach towards LVT. We performed a systematic review and meta-analysis to investigate the diagnostic performance of three methods of TTE (non-contrast, contrast, and apical wall motion scoring) for the detection of LVT compared to CMR as a reference test. Studies comprising 2113 patients investigated for LVT using both TTE and CMR were included in the meta-analysis. For non-contrast TTE, pooled sensitivity and specificity were 47% [95% confidence interval (CI): 32-62%], and 98% (95% CI: 96-99%), respectively. In contrast, TTE pooled sensitivity and specificity values were 58% (95% CI: 46-69%), and 98% (95% CI: 96-99%), respectively. Apical wall motion scoring on non-contrast TTE yielded a sensitivity of 100% [95% CI: 93-100%] and a specificity of 54% (95% CI: 42-65%). The area under the curve (AUC) values from our summary receiver operating characteristic curve (SROC) for non-contrast and contrast TTE were 0.87 and 0.86 respectively, with apical wall motion studies having the highest AUC of 0.93. Despite high specificity, routine contrast and non-contrast TTE are likely to miss a significant number of LVT, making it a suboptimal screening tool. The addition of apical wall motion scoring provides a promising method to reliably identify patients requiring further investigations for LVT, whilst excluding others from unnecessary testing.

COVID-19–Induced Left Ventricular Thrombus in a Functionally Normal Heart

COVID-19–Induced Left Ventricular Thrombus in a Functionally Normal Heart

Spectrum of intracardiac thrombi in different clinical scenarios at a tertiary care center

Cardiologists frequently encounter intracardiac thrombi in the course of their work. Along with tumor and vegetation, it is one of the most frequent differential diagnoses for intracardiac masses. Cardioembolic stroke patients frequently have intracardiac thrombi in the left ventricle. Although the potential for cerebral emboli persists in a large population of patients with chronic left ventricular (LV) dysfunction, the risk of LV thrombus formation is highest during the first 3 months after acute myocardial infarction. The main risk factors for the development of left atrial thrombi are rheumatic valvular disease, especially mitral stenosis and atrial fibrillation. Right heart chamber thrombi may develop in situ or occur when peripheral venous clots that are on their way to the lungs become stuck, leading to acute pulmonary embolism, and their incidence ranges from 4% to 18%. We are presenting five cases that represent a broad range of clinical circumstances involving intracardiac thrombus. When performed during systole and diastole, echocardiography can detect thrombus as a discrete, echo-dense mass with clearly defined borders that is separate from the endocardium. Since dimensions, shape, regularity or irregularity, and homogeneity are all characteristic features that define the embolic risk and therapeutic management, the morphology and structure of thrombi should be carefully assessed.