Mobile Left Ventricular Thrombus Research Articles

Contemporary early left ventricular thrombus resolution by echocardiography: insight from a longitudinal multicenter registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Multicenter longitudinal data are lacking regarding the incidence and the time needed for total left ventricular thrombus (LVT) regression obtained with contemporary antithrombotic regimens diagnosed with modern echocardiographic technology. Purpose To quantify the effect of antithrombotic therapy on LVT evolution using sequential up-to-date echocardiography in a large cohort of patients with LVT. Methods Ten centers were involved in this observational prospective multicenter study. LVT was defined as an echo-dense mass adjacent to a hypokinetic or akinetic myocardial segment. To be distinguishable from the underlying myocardium, a clear thrombus–blood interface was required and the LVT had to be visible on at least 2 views during the cardiac cycle. Initial follow-up echocardiograph was scheduled at 14±7 days (T0) and 42±7 days (T1). The early resolution was defined when LVT was no longer detected at T1. The use of different anticoagulant regimens and ultrasound contrast was left at the discretion of attending physicians, according to good clinical practice. Results From October 2020 to November 2022, 99 patients with LVT (mean age 66 ± 11 years, 80% men) were identified with echocardiography, in 53% ultrasound contrast was used. Early resolution of LVT was observed in 42%. Echocardiographic characteristics by early resolution of LVT are shown in Table. The independent correlates of early LVT regression were smaller baseline LVT area, higher LVEF, and mobile LVT (p<0.05). Conclusions In this large and well-characterized present-day cohort of patients with LVT, early regression by echocardiography was achieved in less than half of the patients and was mostly related to the size of the LVT and heart function rather than treatment despite a high proportion of antithrombotic therapy. The next step will be to assess the impact of LVT persistence on subsequent clinical outcomes.

Large vessel occlusions requiring repeated mechanical thrombectomy caused by silent myocardial infarction in a young adult

ObjectivesSilent myocardial ischemia, defined as objective evidence of myocardial ischemia without symptoms, is associated with ischemic stroke. Nevertheless, silent myocardial infarction is a rare cause of ischemic stroke, especially in young adults with no medical history. Materials and methodsHerein, we report a young adult patient with acute ischemic stroke treated with repeated mechanical thrombectomy for recurrent large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. ResultsA 40-year-old man was transferred by ambulance to our hospital because of a generalized seizure. He was diagnosed with cerebral infarction and left middle cerebral artery occlusion. We performed intravenous thrombolysis and mechanical thrombectomy. Recanalization was achieved and his symptoms gradually improved. However, the day after treatment he developed bilateral cerebellar infarction and basilar artery occlusion. We performed a second mechanical thrombectomy and recanalization was achieved. Transthoracic echocardiography revealed a mobile left ventricular thrombus. Although he had no previous chest symptomatic episodes, cardiac examination confirmed myocardial infarction of unknown onset. He was diagnosed with acute ischemic stroke with large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. Anticoagulation therapy reduced the amount of thrombus. At 1-year follow-up, he had not experienced any recurrences or symptoms. ConclusionsSilent myocardial infarction should be considered a cause of ischemic stroke in young adults, even without any vascular risk factors. Recurrent large vessel occlusion may occur in patients with left ventricular thrombus, and repeated mechanical thrombectomy should be considered for treatment.

P203 CHALLENGES IN THE MANAGEMENT OF RECTUS MUSCLE HEMATOMA DURING TRIPLE ANTITHROMBOTIC THERAPY IN RECENT ANTERIOR STEMI COMPLICATED BY LEFT ENDOVENTRICULAR THROMBOSIS

Abstract A 69–year–old woman suffering from hypercholesterolemia, GERD, was admitted to our department for anterior ST elevation myocardial infarction and was treated with primary PCI and DES on the mid–distal LAD. Dual antiplatelet therapy (DAPT) with ticagrelor and cardioaspirin was started. The pre–discharge echocardiogram (echo) showed the presence of left ventricular thrombus (LVT) and anticoagulant therapy (enoxaparin and warfarin) was started. On the 9th day the patient complained abdominal pain with onset of chills and hyperthermia and was suspected an uro–septic fever. The day after a mass appeared on the right abdominal wall at the site of the enoxaparin injection and abdominal contrast CT showed a mass of inhomogeneous density, actively supplied by the inferior epigastric artery and its terminal branches, indicative of hematoma of the abdominal rectus muscle. Anticoagulant therapy was suspended. Interventional radiologists in consideration of clinical stability and stable Hb value and the absence of the signs of active arterial bleeding on CT have not indicated an urgent endovascular treatment and DAPT with clopidogrel and cardioaspirin was continued. After V days, echo showed persistent pedunculated and mobile LVT and aspirin was therefore suspended and anticoagulant therapy was reintroduced with fondaparinux 2.5 mg daily. After two days, considering the stability of hematoma dimensions and the Hb values but the persistence of the extremely floating LVT, fondaparinux was increased at dose of 5 mg daily. In the following days, echo showed LVT reworking until its complete disappearance. On the 32th day blood test showed significant reduction in Hb values and a contrast CT showed an increase in size of the hematoma and resumption of micro bleeding. Fondaparinux was stopped and the patient was transferred to the interventional radiology center. Angiography highlights point–like spreads of extravascular contrast from branches of the inferior epigastric artery and branches of the external circumflex iliac artery. Embolization was performed. After a close monitoring of the hemoglobin values and of the echo which showed no LVT and recovery of LV function, in consideration of her thrombotic and hemorragic risks, she was discharged with DAPT with clopidogrel and low dose of aspirin. Abdominal wall hematoma may be a rare complication of subcutaneous enoxaparin therapy especially in STEMI patients undergoing also a DAPT therapy.

Large mobile left ventricular thrombus in a patient with dilated cardiomyopathy: a case report and review of literature

Dilated cardiomyopathy (DCMP) and the resultant left ventricular (LV) dysfunction are risk factors for thrombus formation in the heart. Once formed, depending on their size, location, and mobility, LV thrombi have the tendency to embolise, sometimes with dire consequences. Early detection and treatment are important to reduce thromboembolic events and in resolution of LV thrombus. Two-dimensional (2D) echocardiography is the most commonly used technique for the diagnosis and follow-up of such cases. Here, we present a case of 30 years old female with DCMP with congestive heart failure (CHF) who developed a large mobile LV thrombus and was managed on anticoagulants to prevent distal embolisation. This case highlights that LV thrombi can even occur in patients in sinus rhythm who have reduced LV contractility.

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.

Longitudinally Giant Left Ventricular Thrombus

Incidence of post-infarction left ventricular (LV) thrombus is reduced by modern methods of revascularization and treatment with intensive antithrombotic agents. LV thrombus may be an important cause of morbidity and mortality due to relatively high risk of embolization. Therefore, the diagnosis and appropriate management is crucial. The paper introduces a successful treatment of massive, mobile LV thrombus originating from the apical aneurysm and extending to the left ventricular outflow tract.

Surgical removal of a large mobile left ventricular thrombusvialeft atriotomy

Left ventricular (LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after surgery. We present an alternative approach to thrombectomy in order to minimize the postoperative LV dysfunction. A 37-year-old female with a postpartum cardiomyopathy found to have poor LV function and a large left ventricular apical thrombus (3 cm × 3 cm) attached to the apex by a narrow stalk. Given her severe LV dysfunction, the LV thrombus was approached via left atriotomy under cardiopulmonary bypass. The LV thrombus was easily extracted with gentle traction via the mitral valve. Postoperatively, the patient was discharged home without any embolization event or inotropic support. LV thrombectomy via left atriotomy through the mitral valve could be an alternative option for the patients with poor LV function with a mobile LV thrombus.

Rapid Resolution of Large Mobile Left Ventricular Thrombus with Anticoagulation in Dilated Cardiomyopathy: A Case Report

Development of left ventricular thrombus is a dreaded complication after myocardial infarction and in dilated cardiomyopathy. Early detection and treatment is important as it carries the risk of systemic embolism. Thrombolytic therapy, anticoagulation and surgical removals are considered treatment options in patient with left ventricular thrombus. Resolution of left ventricular thrombus with anticoagulation demonstrate the effectiveness of such therapy in preventing the dreaded complications of clot embolism.

Mobile left ventricular thrombus in left ventricular dysfunction: case report and review of literature

Left ventricular (LV) thrombi carry a high risk of embolization. Therapeutic recommendations like treatment with low molecular heparin and intravenous unfractionated heparin (UFH), thrombolysis or surgical thrombectomy have failed to reach a consensus. A 56-year-old female patient presented in cardiogenic shock to the emergency department. Echocardiography demonstrated a dilated LV with a severely depressed global systolic function and a large LV apical thrombus. Treatment with UFH was initiated as well as a treatment with catecholamines for stabilizing the patient's hemodynamic situation. On the follow-up echocardiographic examination, extensive free-floating parts of the thrombus could be documented. Given the high risk of embolization in a now hemodynamically stable situation, emergency surgical embolectomy was performed. A conservative procedure might be useful for bridging till surgical treatment is available and/or the risk due to surgery is acceptable. In absence of evidence-based guidelines for the treatment of LV thrombi, individualized management options concerning surgical, embolization and bleeding risk must be taken into account.

Idiopathic massive left ventricular thrombus in HIV patient

A 47-year old man with HIV presented with a stroke. Imaging revealed a large mobile left-ventricular thrombus. The mass was resected using a small ventriculotomy with good early postoperative prognosis. Thrombus etiology is likely related to HIV pathology.

A large left ventricular thrombus

The discovery of a left ventricular mass obliges the clinician to perform a differential diagnosis including tumour or lipoma versus thrombus and its assessment presents important clinical implications. Dilated cardiomyopathy has been associated with left ventricular thrombosis which leads to substantial morbidity and mortality as a site for peripheral emboli. There are some studies on patients with dilated cardiomyopathy showing altered hemostasis and platelet behavior despite sinus rhythm. An increased incidence of thromboembolism is also well recognized in patients with left ventricular systolic dysfunction complicating history of myocardial infarction. Clinical dilemmas in treating left ventricular thrombus have been described too. We present a case of a large mobile left ventricular thrombus in a 71-year-old Italian man with dilated cardiomyopathy and history of myocardial infarction.

Catheter Ablation for Ventricular Tachycardia

Sustained ventricular tachycardia (VT) is an important cause of morbidity and sudden death in patients with heart disease.1 Implantable cardioverter-defibrillators (ICDs) terminate VT episodes, reducing the risk of sudden death. Recurrent VT develops in 40% to 60% of patients who receive an ICD after an episode of spontaneous sustained VT. A first episode of VT occurs in ≈20% of patients within 3 to 5 years after ICD implantation for primary prevention of sudden death in high-risk groups.2–4 ICD shocks reduce quality of life and are associated with an increased risk of death.2–4 Antiarrhythmic drug therapy with amiodarone or sotalol reduces VT episodes but with disappointing incidence of side effects and efficacy.2 Catheter ablation is useful for reducing VT episodes and can be life-saving when VT is incessant.1,5,6 Idiopathic VTs occur in patients without structural heart disease and rarely cause sudden death. Electrophysiological study with catheter ablation is often warranted to confirm the diagnosis, to provide further evidence for the absence of ventricular scar or other disease, and often to cure the arrhythmia. Ablation is also an option for symptomatic nonsustained VT and frequent ventricular ectopy in these patients.1 The appearance of the VT on ECG often suggests its likely cause and associated heart disease (Figure 1). Monomorphic VT has the same QRS complex from beat to beat, indicating repetitive ventricular activation from a structural substrate or focus that can be targeted for ablation. Most are due to reentry through regions of ventricular scar.7 Figure 1. ECG types of VT and most common causes are shown with characteristic ECG features of selected VTs. LBBB indicates left bundle-branch block; LVOT, LV outflow tract; RBBB, right bundle-branch block; L, left; and R, right. Polymorphic VTs have a changing ventricular activation sequence that can be due to …

Fibrinolytic treatment in left ventricular mobile thrombi with low ejection fraction: results and follow-up of seven cases

Left ventricular mobile thrombi carry high risk of embolism and need early treatment in which the appropriate treatment is still controversial. Because most patients with mobile thrombi have low ejection fraction and also accompanying heart failure symptoms, decision of surgical treatment is not always easy and thus effective medical treatment is crucial. In this paper we present, treatment and follow-up of seven patients with mobile thrombi who underwent fibrinolytic treatment between 2002 and 2006. In four cases, mobile thrombi disappeared completely while echocardiographically regressed to lower size with decreased mobility in the other three patients. On 6th month follow-up, complete lysis of the thrombi in six patients was observed with warfarin treatment. No major complications were seen in the patients. In case of mobile left ventricular thrombi with concomitant low ejection fraction and heart failure fibrinolytic treatment might be a therapeutic option.

Cardiogenic cerebral emboli: diagnosis and treatment.

New technology has made it possible to identify cardiogenic cerebral emboli more easily and reliably. In recent years echocardiography, and in particular transesophageal echocardiography, has become the gold standard for the identification of cardiogenic sources of emboli, whereas transcranial Doppler is an important technique for the detection of cerebral emboli. Treatment strategies are better established and more accurate, if more complex, since the completion of large randomized trials. For primary prevention of stroke in elderly patients with nonvalvular atrial fibrillation, warfarin is generally indicated, yet in patients aged 60-75 years with no risk factors, aspirin may be sufficient. Warfarin is hazardous in older high-risk patients even at the 'low intensity' of the anticoagulation regimen; even lower doses are therefore being tested. Heparin and aspirin are indicated for short-term treatment of acute myocardial infarction, whereas for long-term treatment aspirin is still the drug of choice. However, if mobile left ventricular thrombi are present, warfarin is superior and new studies have shown its effectiveness for all myocardial infarction survivors. Combined treatment of warfarin and aspirin appears to be most effective in patients with mechanical prosthetic valves.

Dilated Cardiomyopathy Complicated by a Pedunculated and Mobile Left Ventricular Thrombus on Ruptured False Tendons

A 68-year-old man was admitted with congestive heart failure. He was treated with diuretics and digitalis; thereafter, the two-dimensional echocardiogram suggested a pedunculated and mobile left ventricular thrombus. He underwent surgical thrombectomy because of the high risk of systemic embolization. To our knowledge, this is the first case of dilated cardiomyopathy with a mobile left ventricular thrombus that was attached to ruptured false tendons.

Lysis of mobile left ventricular thrombi during acute myocardial infarction with urokinase

Left ventricular (LV) thrombi occur in about onethird of patients who have had an acute myocardial infarction (AMI). 1,2 Autopsy 3 and echocardiographic studies 1,2 suggest that patients with protruding and mobile LV thrombi are at risk of systemic embolization. Kremer et al 4 reported the successful use of urokinase for lysis of protruding and mobile LV thrombi during AMI but no further reports followed this initial communication. We report the effect of urokinase on mobile LV thrombi in a patient with AMI.