Management Of Left Ventricular Thrombus Research Articles

Contemporary Review of the Management of Left Ventricular Thrombus

Although there is established evidence for the treatment of left ventricular thrombus (LVT) at the outset, the subsequent management of these patients is less well-defined. This review discusses the currently available evidence for the initial type and duration of anticoagulation for LVT and explores potential treatment options after the initial period of anticoagulation. Of 2,052 studies screened, 32 studies (with three randomised controlled trials) were included. The initial anticoagulation strategy was either warfarin or direct oral anticoagulants, with the majority of studies showing similar outcomes. If LVT persists, studies recommended continuing anticoagulation (n=11/17) or switching to a different class of anticoagulant (n=7/17). After resolution, five studies recommended continuing anticoagulation in the presence of high-risk features of recurrence (i.e. persistently depressed left ventricular ejection fraction and/or apical wall dyskinesia). Medical management should be optimised, together with the appropriate revascularisation strategy, as clinically indicated. Synthesising the evidence, a practical algorithm for the management of LVT is proposed.

Review of the Etiology, Diagnosis, and Management of Left Ventricular Thrombus.

The incidence of left ventricular (LV) thrombus following acute myocardial infarction has declined significantly due to recent advancements in reperfusion and antithrombotic therapies. The development of LV thrombus depends on Virchow's triad: endothelial injury following myocardial infarction, blood stasis from LV dysfunction, and hypercoagulability. Diagnostic modalities for LV thrombus include transthoracic echocardiography and late gadolinium enhancement cardiac magnetic resonance imaging. Anticoagulation with direct oral anticoagulants or vitamin K antagonists for 3 months following initial diagnosis of LV thrombus remains the treatment of choice for LV thrombus. However, further evidence is needed to demonstrate the noninferiority of direct oral anticoagulants compared with vitamin K antagonists for the prevention of thromboembolic events.

Conservative Management of Left Ventricular Thrombus Patient with Decreased Systolic Function: A Case Report

Highlights: It provides insight into the management of LVT. Abstract: Case Summary. A 35-year-old male complained shortness of breath for 1 month, had worsened in the last 3 days. When walking 3-5 steps, the patient already felt dyspneu. When sleeping, the patient must be in a semi-sitting position, and sometimes still feels tight. The patient also complained of occasional chest pain. The patient is known to have a history of heart disease, and a history of taking drugs such as candesartan, ISDN and bisoprolol. Discussion. Left ventricular thrombus (LVT) is a frequent and potentially dangerous complication of acute myocardial infarction and is associated with increased risk of systemic embolization. Incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Management of LVT is primarily based on studies before the widespread use of potent pharmacological and interventional therapies such as primary percutaneous coronary intervention, especially in the setting of acute myocardial infarction. Though advances in diagnostic technology have improved detection of LVT, clinicians face several uncertainties in the management of LVT in daily practice.

Contemporary review of the management of left ventricular thrombus

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left ventricular thrombus (LVT) is a known complication of acute myocardial infarction (AMI) and other cardiomyopathies. LVT increases the risk of stroke and systemic embolism, hence treatment with oral anticoagulation is indicated. While the initial treatment options for LVT is clear, the management of patients after the initial duration of anticoagulation is more complex and varied. Purpose We aimed to undertake a comprehensive literature review to study the currently available evidence regarding not only the initial type and duration of anticoagulation for LVT, but also potential treatment options after the initial period of anticoagulation in the setting of both LVT persistence and resolution. Methods MEDLINE, EMBASE, Scopus, and Google Scholar were searched from inception to August 2022. Data from randomized controlled trials (RCTs), observational studies and case series discussing management of LVT were included in this summarized synthesis. Results Of 2050 studies screened, 30 studies (24 observational studies, 3 case series, 2 RCTs, 1 non-randomized, open-label trial) were included. A total of 17 studies compared warfarin with direct oral anticoagulants (DOACs) for the initial anticoagulation strategy, with the vast majority showing similar outcomes (Table 1). Half (n = 9/18) of the studies repeated imaging between 3-6 months. All studies (n=30) used transthoracic echo with or without contrast as the imaging modality of choice, with selected patients undergoing computed tomography (CT) or cardiac magnetic resonance (CMR). If the LVT persisted, most studies recommended continuing anticoagulation (n = 11/16, 69%) or switching to a different class of anticoagulants (n = 6/16, 38%). In the event of LVT non-resolution, high-risk features of embolization (protruding, mobile vs layered clot) may aid in the discussion of risk and benefit of long-term anticoagulation. Even upon resolution of the LVT, some studies (n=5) recommend continuing anticoagulation in the presence of high-risk features of recurrence (eg. persistently depressed left ventricle ejection fraction (LVEF) and/or apical wall dyskinesis). Regardless, medical management should be optimized together with the appropriate revascularization strategy as clinically indicated. Conclusions Current evidence on the management of LVT is limited. This updated review summarizes the available evidence for the management for LVT. Evidence-based recommendations on the management of these patients is warranted to appropriately guide clinicians.

Improving the management of left ventricular thrombus in a tertiary cardiology centre: a quality improvement project

Left ventricular (LV) thrombus is an increasingly recognised complication following anterior myocardial infarction and non-ischaemic cardiomyopathy. Whilst vitamin K antagonists (VKA) remain the only approved therapeutic option to reduce the...

Abstract 11476: The Clot Thickens: Massive Left Ventricular Thrombus After Sub-Acute Myocardial Infarction

Introduction: Left ventricular thrombus (LVT) following myocardial infarction (MI) can affect up to 19.2% of patients with anterior wall MI. The mechanism is thought to be due to stasis from LV regional wall akinesia, endothelial injury from prolonged ischemia, and hypercoagulability from acute coronary syndrome. In patients with LVT after MI, anticoagulation choice and duration is still a matter of debate. Case Report: A 51-year-old woman with diabetes and prior anterior wall MI with LVT presented with non-healing diabetic leg wounds. One year ago at the time of the MI, transthoracic echocardiogram (TTE) showed a 4.0 x 1.3 cm mural thrombus. She was discharged on prasugrel and apixaban. Apixaban was discontinued after five months, with follow-up TTE showing resolution of LVT, with 30% LV ejection fraction and evidence of LV remodeling. This hospitalization, while awaiting discharge, the patient developed sudden undifferentiated shock requiring norepinephrine and dobutamine. Repeat TTE revealed a 6.0 x 5.5 cm apical LVT filling more than 50% of the LV cavity, with unchanged LV ejection fraction. Heparin drip was started. Prior to evaluation by cardiothoracic surgery, patient became acutely unresponsive, had a cardiac arrest, and expired. Cause of death suspected to be due to cardioembolic events, worsened with mixed shock and low-output heart failure from LVT. Discussion: Management of LVT after MI remains unclear. Current guidelines indicate treatment with vitamin K antagonist (VKA) for at least 3 - 6 months, and consideration of prophylactic anticoagulation with VKA for patients with apical dyskinesis after MI. Retrospectively, this patient may have benefitted from a prolonged course of anticoagulation given the extent of LV remodeling five months after initial event despite resolution of LVT. Anticoagulation must be evaluated on a case-by-case basis weighing propensity of thrombotic events with risk of bleeding.

Evidence-Based Recommendations: Management of Left Ventricular Thrombus Post-Acute Myocardial Infarction.

One of the potential complications of acute myocardial infarction is left ventricular thrombus (LVT). The incidence of LVT following acute myocardial infarction has decreased dramatically with early invasive reperfusion techniques or fibrinolysis. However, the risk of LVT formation remains significant and is associated with an increased risk of systemic embolism, stroke, cardiovascular events, and even death. Current guidelines indicate that dual antiplatelet therapy and anticoagulation therapy for at least 3 months can reduce the risk of these events. While vitamin K antagonist is the preferred oral anticoagulant, there is growing evidence to support the use of direct-acting oral anticoagulants in LVT management. Cardiac magnetic resonance has shown the highest diagnostic accuracy for LVT assessment, followed by echocardiography with contrast agents. This article serves as a general review of the pathophysiology, diagnosis, and management of LVT.

Abstract 12301: Anticoagulation for Left Ventricular Thrombus: An Updated Meta-Analysis of Stroke or Systemic Embolization Outcomes

Introduction: Thromboembolic events including stroke or systemic embolization (SSE) are the most dreaded complications in patients who develop left ventricular (LV) thrombus. Vitamin K antagonists (VKAs) and non-vitamin K oral anticoagulants (NOACs) have been used in the management of LV thrombus however the efficacy of these treatment strategies have been rarely studied in head-to-head trials. Our aim was to study the differences in embolization outcomes in patients with LV thrombus on either NOACs or VKAs. Methods: A comprehensive search of electronic databases was conducted for studies comparing VKAs and NOACs in patients with LV thrombus. Event level data were extracted from studies for each arm and used to calculate the risk ratio (RR) with 95% confidence intervals (CI) which were pooled for the effect of original treatment allocation on the outcome of SSE. Random effects model was used to calculate the risk ratio. Results: We found a total of 12 studies from which 2281 patients were identified with LV thrombus and were treated with anticoagulation. 596 (26.13%) received NOACs and 1685 (73.87%) received VKAs. Events of SSE occurred in 92 (15.44%) patients on NOACs and 307 (18.22%) patients on VKAs. Overall, patients treated with NOACs had similar rate of SSE events as compared to patients treated with VKAs using random effects model (RR: 1.02 [95% 0.64-1.65], p=0.08, I 2 =39%). Conclusions: This meta-analysis suggests that the use of NOACs is associated similar rate of SSE events in patients with LV thrombus as compared to the use of VKAs. Additional prospective studies are required to determine the most effective anticoagulant strategy for patients with LV thrombus.

Abstract 12654: Direct Oral Anticoagulants (DOAC) versus Warfarin for the Treatment of Left Ventricular Thrombus (LVT) in Patients With or Without Cardiorenal Comorbidities, Including CKD (Chronic Kidney Disease) and Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background: The medical management of left ventricular thrombus (LVT) is very challenging due to the risk of embolic events. The current body of evidence supports the use of DOACs (direct oral anticoagulants) as safe substitutes to vitamin K antagonists/warfarin. We aim to identify the credibility of the evidence-based claims that advocate the safety/efficacy of DOACs in comparison to warfarin therapy for LVT patients. Methods: We systematically explored PubMed/Medline, JSTOR, Google Scholar, and Cochrane Library to identify relevant studies published between January 2006 and April 2021. The included studies categorically compared various clinical endpoints related to the safety/efficacy of DOACs versus warfarin in LVT scenarios. Results: We extracted 23 studies on 172,038 adult patients who received treatment for LVT and/or cardiorenal comorbidities via DOACs or warfarin. The odds ratios for all-cause mortality (OR: 1.08, 95% CI 0.69, 1.71), arterial thrombus (OR: 0.74 [95% CI 0.03, 18.76]), bleeding complications (OR: 1.16 [95% CI 0.67, 2.02]), composite of deep venous thrombosis or pulmonary embolism (OR: 0.95 [95% CI 0.10, 8.99]), hemorrhagic stroke (OR: 0.53 [95% CI 0.02, 13.30]), composite of stroke or systemic embolism (OR: 1.08, 95% CI 0.64, 1.83), systemic embolism (OR: 0.53 [95% CI 0.02, 13.30]), and rate of thrombus resolution for DOACs (versus warfarin) (OR: 1.32 [95% CI 0.66, 2.62]) supported their safety/efficacy in LVT treatment. The subgroup analysis affirmed the safety/efficacy of betrixaban and rivaroxaban (as compared to warfarin) in minimizing the episodes of stroke/ischemic stroke and clinically relevant/intracranial hemorrhage in patients with/without cardiorenal comorbidities. Conclusion: We found no difference in therapeutic efficacy and safety of DOACs as compared to warfarin in managing the clinical complications of left ventricular thrombus. The findings advocate the need for prospective randomized controlled trials to validate the safe replacement of warfarin with DOACs in LVT patients.

Direct Oral Anticoagulants Versus Warfarin in Left Ventricular Thrombus: A Systematic Review and Meta-Analysis.

There are conflicting results regarding the safety and efficacy of direct oral anticoagulants (DOACs) in the management of left ventricular thrombus (LVT) compared with the vitamin K antagonist warfarin. What is the safety and efficacy of DOACs in the management of LVT compared with warfarin? Randomized clinical trials and cohort studies in the MEDLINE and Cochrane databases from inception till April 4, 2021. The present analysis is a systematic review and meta-analysis. Desired outcomes were all-cause mortality, complete resolution of LVT, stroke and systemic emboli, and major bleeding. The risk ratio (RR) of the outcomes and 95% confidence intervals (CIs) were calculated using a random-effects modeling approach. Twelve studies with a total of 2322 patients were included. There was no difference between the 2 interventions in the resolution of LVT [RR 0.97 (CI 0.93-1.02)], stroke and systemic embolism [RR 0.95 (CI 0.63-1.45)], bleeding [RR 1.14 (CI 0.81-1.60)], and all-cause mortality [RR 0.99 (CI 0.67, 1.46)]. DOACs and warfarin have comparable safety and efficacy outcomes in the management of LVT.

Meta-Analysis Comparing Direct Oral Anticoagulants to Vitamin K Antagonists for The Management of Left Ventricular Thrombus

ABSTRACT Introduction: To compare vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) treatment in patients with left ventricular (LV) thrombus. The primary outcome was stroke or systemic embolism (SSE). Secondary outcomes were thrombus resolution, bleeding, and death. Areas covered: Five observational studies were included (total n = 700; VKAs n = 480; DOACs n = 220). There was a trend toward less SSE with VKAs compared to DOACs (5.2% vs. 9%; odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.29–1.01, p = 0.05). No significant difference between VKAs and DOACs in rates of thrombus resolution (61.6% vs. 56.8%; OR = 1.00, 95% CI = 0.58–1.73, p = 0.99), bleeding (8.2% vs. 4.4%; OR = 1.62, 95% CI = 0.69–3.77, p = 0.27), or death (12.7% vs. 11.8%; OR = 1.09, 95% CI = 0.59–2.0, p = 0.79) was noted. In non-primary percutaneous coronary intervention setting, VKAs were associated with less SSE in prespecified analysis (5.2% vs.10.6%; OR = 0.48, 95% CI = 0.25–0.93, p = 0.03). Expert opinion: The current meta-analysis suggests a trend toward higher SSE with the use of DOACs compared to VKAs. Our recommendation is for VKAs to retain the preferred management of LV thrombus with cautious off-label use of DOACs.

Assessment of non-vitamin K antagonist oral anticoagulants for the management of left ventricular thrombus.

Although several studies have assessed the effect of non‐vitamin K antagonist oral anticoagulants (NOACs) relative to that of vitamin K antagonists (VKAs) in patients with left ventricular thrombus, the results remain controversial. Herein, a meta‐analysis was performed to compare the effectiveness and safety of NOACs versus VKAs for the treatment of left ventricular thrombus. We systematically searched the Cochrane Library, PubMed and Embase databases until November 2020 for studies that compared the effects of NOACs versus VKAs in patients with left ventricular thrombus. The treatment effects were expressed as odds ratios (ORs) with 95% confidence intervals (CIs) and pooled by a random‐effects model. Seven retrospective studies involving 865 patients with left ventricular thrombus (266 NOAC and 599 VKA users) were included. The pooled analysis suggested no difference in the rate of thrombus resolution between the NOAC and VKA groups (OR = 0.83, 95% CI 0.61–1.13). There were also no differences in the rates of stroke or systemic embolism (OR = 0.62, 95% CI 0.20–1.97), bleeding events (OR = 0.73, 95% CI 0.37–1.45), or all‐cause death (OR = 0.92, 95% CI 0.50–1.69) between patients treated with NOACs and those treated with VKAs. In addition, the rates of thrombus resolution, stroke or systemic embolism, bleeding events, and all‐cause death between NOAC‐ and warfarin‐treated patients were also similar. Our current evidence suggested that NOAC and VKA users had similar rates of thrombus resolution and clinical outcomes among patients with left ventricular thrombus. Further large‐scale prospective studies should confirm our results.

Management of left ventricular thrombus: a narrative review.

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.

Use of Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: Systematic Review of Current Literature.

Left ventricular thrombus (LVT) is an important complication in the setting of systolic dysfunction, particularly after acute myocardial infarction. Current guidelines recommend the vitamin-K antagonist, warfarin, for the treatment of LVT. The direct oral anticoagulants (DOACs) are being increasingly used for the management of this entity, despite lack of randomized trials in support of it or knowledge about their efficacy. We aimed to assess the frequency of use and the efficacy of DOACs in the treatment of LVT. We searched published articles in Google Scholar, PubMed, MEDLINE, and Embase from the introduction of DOACs in any therapy until April 2018. Reports describing patients diagnosed with LVT and who were treated with a DOAC were examined. Patient characteristics, comorbidities, pharmacologic treatments, and outcomes were collected. The primary end points of this study were thrombus resolution and time to resolution. Other end points were bleeding and thromboembolic events. Thirty articles describing 41 patients were analyzed. The most common risk factors for LVT formation were male gender, ischemic heart disease, and low ejection fraction. Most patients were treated with rivaroxaban (51.2%), followed by apixaban (26.8%) and dabigatran (22%). Patients were treated with DOAC alone (46.3%), DOAC and aspirin (12.2%), DOAC and clopidogrel (2.4%), and triple therapy (39%). Thrombus resolution success rate was 81%, 100%, and 88.9% for rivaroxaban, apixaban, and dabigatran, respectively. The median time of thrombus resolution was 40 days, 36 days, and 24 days for rivaroxaban, apixaban, and dabigatran, respectively. One nonfatal bleeding event and one stroke event were reported while on a DOAC. The use of DOACs is a reasonable alternative to vitamin-K antagonists in the management of LVT.

Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus.

AimsLeft ventricular (LV) thrombus is increasingly detected in patients with and without ischaemic heart disease due to the increased availability of cardiac magnetic resonance imaging. Risk factors include anterior ST elevation myocardial infarction, delayed reperfusion therapy, and non‐ischaemic cardiomyopathy with severe LV systolic dysfunction. We aimed to report the characteristics and outcomes of patients with LV thrombus treated with either vitamin K antagonist (VKA) or direct oral anticoagulants (DOAC) with a view to describing differences in efficacy, specifically, subsequent thromboembolic events, thrombus resolution, and also side effects of therapy including clinically significant bleeding.Methods and resultsWe conducted a retrospective, observational cohort study of patients diagnosed with LV thrombus between 1 December 2012 and 30 June 2018 and treated with either DOAC or VKA. We recorded patient demographics, past medical history, prescribed medications, and baseline investigations. The primary outcomes were rates of thromboembolism and clinically significant bleeding, with secondary outcomes of thrombus resolution on repeat cardiac imaging, repeat hospitalization, and all‐cause mortality. During the study period, 84 patients were diagnosed with and managed for LV thrombus. Of these, 62 received VKA and 22 DOAC including 13 prescribed rivaroxaban, eight apixaban, and one dabigatran. Most patients 75 (89%) were male with an average age of 62 ± 14 years. Ischaemic heart disease was the cause of LV impairment in 73 (87%) patients. Baseline characteristics were similar between groups at baseline. Most n = 55 (65%) were co‐prescribed a single antiplatelet agent and 32 (38%) received dual‐antiplatelet therapy. During an average follow‐up of 3.0 ± 1.4 years, there were no statistically significant differences between VKA and DOAC in rates of stroke (2% vs. 0%, P = 0.55), other thromboemboli (2% vs. 0%, P = 0.55), or clinically significant bleeding (10% vs. 0%, P = 0.13). The average interval to cardiac imaging follow‐up was 233 ± 251 days and was not different between groups (P = 0.83), and there was no difference in the rate of resolution of thrombus (76% vs. 65% P = 0.33). Rehospitalization (50% vs. 45%: P = 0.53) and all‐cause mortality (10% vs. 14%; P = 0.61) were also similar.ConclusionsOur data suggest that DOACs are likely to be at least as effective and safe as VKA for stroke prevention in patients with LV thrombus and, despite their lack of a licence for this indication, are therefore likely to represent a reasonable and more convenient option for this setting. The optimal timing and type of anticoagulation for LV thrombus, as well as the role of screening for high‐risk patients, should be tested in prospective, randomized trials.

Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus

BackgroundContemporary data are lacking regarding the prognosis and management of left ventricular thrombus (LVT). ObjectivesThe purpose of this study was to quantify the effect of anticoagulation therapy on LVT evolution using sequential imaging and to determine the impact of LVT regression on the incidence of thromboembolism, bleeding, and mortality. MethodsFrom January 2011 to January 2018, a comprehensive computerized search of LVT was conducted using 90,065 consecutive echocardiogram reports. Only patients with a confirmed LVT were included after imaging review by 2 independent experts. Major adverse cardiovascular events (MACE), which included death, stroke, myocardial infarction, or acute peripheral artery emboli, were determined as well as major bleeding events (BARC ≥3) and all-cause mortality rates. ResultsThere were 159 patients with a confirmed LVT. Patients were treated with vitamin K antagonists (48.4%), parenteral heparins (27.7%), and direct oral anticoagulants (22.6%). Antiplatelet therapy was used in 67.9% of the population. A reduction of the LVT area from baseline was observed in 121 patients (76.1%), and total LVT regression occurred in 99 patients (62.3%) within a median time of 103 days (interquartile range: 32 to 392 days). The independent correlates of LVT regression were a nonischemic cardiomyopathy (hazard ratio [HR]: 2.74; 95% confidence interval [CI]: 1.43 to 5.26; p = 0.002) and a smaller baseline thrombus area (HR: 0.66; 95% CI: 0.45 to 0.96; p = 0.031). The frequency of MACE was 37.1%; mortality 18.9%; stroke 13.3%; and major bleeding 13.2% during a median follow-up of 632 days (interquartile range: 187 to 1,126 days). MACE occurred in 35.4% and 40.0% of patients with total LVT regression and those with persistent LVT (p = 0.203). A reduced risk of mortality was observed among patients with total LVT regression (HR: 0.48; 95% CI: 0.23 to 0.98; p = 0.039), whereas an increased major bleeding risk was observed among patients with persistent LVT (9.1% vs. 12%; HR 0.34; 95% CI: 0.14 to 0.82; p = 0.011). A left ventricular ejection fraction ≥35% (HR: 0.46; 95% CI: 0.23 to 0.93; p = 0.029) and anticoagulation therapy >3 months (HR: 0.42; 95% CI: 0.20 to 0.88; p = 0.021) were independently associated with less MACE. ConclusionsThe presence of LVT was associated with a very high risk of MACE and mortality. Total LVT regression, obtained with different anticoagulant regimens, was associated with reduced mortality.

Antithrombotic therapy and cardiovascular events in patients with left ventricular thrombus

The optimal management of left ventricular thrombus (LVT) is unknown, particularly with the emergence of the non-vitamin K antagonist anticoagulants (NOACs). To identify the independent correlates of LVT regression and clinical outcomes. A computerized case sensitive search on 90 065 consecutive echocardiograms performed between January 2011 and December 2017 identified patients with a LVT. Repeated echocardiographic data, treatment and major adverse cardiac events (MACE), including death, stroke, myocardial infarction or acute peripheral artery emboli were analyzed as well as major bleeding events (BARC ≥ 3) and all-cause mortality. We included 159 patients with an LVT confirmed by two independent experts. Patients were treated by vitamin K antagonists (48.4%), parenteral heparins (27.7%) and NOACs (22.6%) with additional antiplatelet therapy in 67.9% of the population. Total LVT regression was reached in 62.3% of the patients in a median time of 103 [32–392] days. The independent correlates associated with LVT regression were a non-ischemic cardiomyopathy (HR 0.36; 95%CI [0.19–0.69], P = 0.002) and a smaller baseline thrombus area (HR 0.66; 95%CI [0.45–0.96], P = 0.031). Cardiovascular events were frequent with 37.1% of MACE, 18.9% of major bleeding and 13.2% of all-cause mortality during a median follow-up of 632 [187–1126] days. A left ventricular ejection fraction >35% (HR 0.46; 95%CI [0.23–0.93], P = 0.029) and an anticoagulation therapy > 3 months (HR 0.42; 95%CI [0.20–0.88], P = 0.021) were independently associated with less MACE. A reduced risk of mortality was observed among patients that obtained a total LVT regression (HR 0.48; 95%CI [0.23–0.98]; P = 0.039) ( Fig. 1 ). The presence of LVT was associated with a very high risk of MACE and mortality. Total thrombus regression, obtained with either vitamin K antagonists or NOACs, led to a better prognosis.

The prognostic effect of left ventricular thrombus formation after acute myocardial infarction in the contemporary era of primary percutaneous coronary intervention: A meta-analysis

Backgrounds: The prognosis and management of left ventricular thrombus (LVT) following acute myocardial infarction (AMI) have not been well evaluated since the advent of primary percutaneous coronary intervention (PCI). We therefore conducted a meta-analysis to assess the prognostic effect of LVT after AMI in primary PCI era and investigate the impact of triple therapy on outcomes. Methods: We searched MEDLINE, EMBASE and the Cochrane Library for studies conducted in primary PCI era up to 29 March 2019, compering the incidence of embolic events and mortality after AMI between LVT patients and Non-LVT patients. Random-effect models were used. Subgroup analysis was done by comparing triple therapy treated LVT group with Non-LVT group. Result: A total of 12 studies were included. LVT was associated with increased risk of embolic events and long-term mortality (RR 3.97, 95%CI 2.68–5.89, P < 0.0001; RR 2.34, 95%CI 1.38–3.96, P = 0.002). Subgroup analysis was also done by comparing triple therapy treated LVT group with Non-LVT group. Despite a downward tendency was observed, the embolic risk of triple therapy subgroup was higher than non-LVT group (RR 2.79, 95%CI 1.32–5.91, P = 0.007). Triple therapy subgroup had a similar mortality rate compared with non-LVT group (RR 0.93, 95%CI 0.34–2.52, P = 0.88). Conclusion: In primary PCI era, LVT formation after AMI indicated a fourfold increased embolic risk and twofold long-term mortality rate. Triple therapy may be a safe way to improve the outcomes, but still need to be confirmed by future trials.

Oral factor Xa inhibitors for the treatment of left ventricular thrombus: a case series

Left ventricular thrombus (LVT) formation usually necessitates short term anticoagulation for thrombus resolution and to prevent embolic events. Historically, vitamin K antagonist therapy has been the treatment of choice. However, with the advent of direct acting anticoagulants, their role in the management of LVT is not clear. Patients were included if they had received rivaroxaban or apixaban for more than 1 day for LVT documented on imaging. The primary objective was resolution of LVT at 3 months based on assessment by an independent cardiologist review of initial and subsequent imaging results. The principle safety objective was to assess major or clinically relevant non-major bleeding using GUSTO, TIMI, and BARC bleeding criteria. During the 2-year study period seven patients were treated with rivaroxaban and three with apixaban. Two patients who had received apixaban and one on rivaroxaban were lost to follow up. In those with an initial and follow-up ECHO (n = 6) the median time to follow up imaging was 214 (IQR 33-414) days and complete LVT resolution was observed in 83% of patients. One patient on rivaroxaban had a bleeding events that was minimal (TIMI), Type 2 (BARC), or classified as mild (GUSTO) due to pulmonary hemorrhage. In those deemed not to be a candidate for vitamin K antagonist the use of rivaroxaban or apixaban may be a considered in the treatment of LVT. Further research in this area is needed to assess the efficacy and safety of using FXAI for treatment of LVT.

O21-4 - Incidence and Predictors of Thromboembolic Events after Anticoagulant Therapy in Patients with Left Ventricular Thrombus

Background: Left ventricular thrombus (LVT) occurs in patients with LV dysfunction and is associated with increased thromboembolic risk. The management of LVT is important clinical issue that we encounter in daily practice. However, data regarding the incidence of thromboembolism and its predictive factors are limited. Methods: We retrospectively investigated 57 consecutive patients (mean age, 63 ± 15years; mean EF, 43 ± 16%) who showed LVT and were treated with anticoagulant therapy. The incidence of thromboembolism was examined, and the etiologies of LV dysfunction, clinical factors and transthoracic echocardiographic parameters were evaluated. The size and morphology of LVT were also examined with echocardiography. Results: The etiologies of LV dysfunction were ischemic cardiomyopathy in 37 patients, dilated cardiomyopathy in 7, hypertrophic cardiomyopathy in 6, stress-induced cardiomyopathy in 5, and others in 2. Thromboembolism occurred in 8 (14%) at a median of 8 days after anticoagulant therapy (stroke, 6; others, 2). Among 49 patients without thromboembolism, LVT decreased in size in 46, and was unchanged in 3. Protruding or mobile thrombus were significantly related to thromboembolism, while the size was not. The incidence of ischemic cardiomyopathy was also higher in patients with thromboembolism than those without. Conclusions: In patients with LVT, the incidence of thromboembolism after anticoagulant therapy was unexpectedly high (14%). Preventive thrombectomy may be considered in patient with protruding and/or mobile LVT.