Presence Of Left Ventricular Thrombus Research Articles

Incidence of left ventricle thrombus formation in patients with STEMI in the current era of antithrombotic treatment

Abstract Funding Acknowledgements None. Introduction Left ventricular (LV) thrombus formation is a serious complication of acute ST-segment elevation myocardial infarction (STEMI) which may result in ischemic stroke and systemic thromboembolism. There is limited evidence on the incidence and impact of LV thrombus in STEMI patients in the current era of antithrombotic treatment. Purpose To evaluate the incidence of LV thrombus formation in STEMI patients and to assess clinical predictor factors of LV thrombus formation leading to in-hospital major cardiac events (MACCE). Methods We prospective collected data from 504 STEMI patients treated with primary percutaneous intervention (PCI) in our large volume university hospital from April 2019 to September 2019. All patients underwent echocardiography examination at presentation and at hospital discharge. Results Mean age of the patients was 66.2 years and 78.8% were male. The incidence of LV thrombus formation was 5% in overall cohort and 9.4% in anterior STEMI. Among patients with LV thrombus, the majority had anterior STEMI (96% vs 48.4%; p<0.001), lower LV ejection fraction (LVEF)(35% vs 43%; P<0.001), more increased LV dimension /volume (36%vs7.3%; p<0.001), more apical aneurism/dyskinesia presence (36% vs 9%; p<0.001), longer ischemia time (25 hours vs 14 hours; p<0.002), more increased TPI values (p-0.22) and underwent less coronary angiography (p<0.02) and primary PCI (P=0.021). Increased LV dimension/volume was associated with 3.35 times higher risk of having LV thrombus (p=0.023). Also anterior STEMI was associated with 14 times higher risk of having LV thrombus=0.012. Patients with LV thrombus had a numerically higher incidence of in-hospital MACCE events (20% vs 13.5%; p=0.36). Conclusion The incidence of LV thrombus formation in STEMI still remain high regardless of primary PCI treatment and current antithrombotic treatment, and is higher in patients with anterior STEMI, lower LVEF, adverse ventricular remodeling, apical aneurism/dyskinesia presence, late hospital presentation and longer ischemia time. The presence of LV thrombus was independently associated with in-hospital MACCE events.

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.

Left ventricular thrombus in a patient with recurrent ischemic stroke events—The role of echocardiography

Cardiac ultrasound is recommended in investigating ischemic stroke events. There is increasing evidence that direct oral anticoagulants can be safely used instead of vitamin K antagonists in the setting of left ventricular thrombus. Cardioembolic stroke is responsible for an increasing number of ischemic strokes. Compared to other causes of stroke, cardioembolic strokes affect a larger brain area. Left ventricular (LV) thrombi account for up to 10% of cardioembolic strokes. It is essential to identify patients at high risk of LV thrombus formation, such as patients with a history of myocardial infarction, patients with reduced ejection fraction, or patients with cardiomyopathies. We present a patient with an ischemic stroke, and the cardiac ultrasound revealed a reduced ejection fraction and the presence of LV thrombus at the apex. The patient had no prior history of cardiovascular diseases. Even in a resource-limited setting, cardiac ultrasound is recommended to investigate stroke or transient ischemic attack events, especially in patients with a prior history of myocardial infarction. Although patients with LV thrombus should be treated with oral anticoagulants for at least 3 months, the role of direct oral anticoagulants and the optimal period of anticoagulation in this setting needs further investigation.

Left Ventricular Thrombus Management After Acute Myocardial Infarction in Clinical Practice: Results from LEVITATION Survey and Narrative Review.

Left ventricular thrombus (LVT) after ST-elevation myocardial infarction still presents diagnostic and therapeutic challenges. The LEVITATION survey was designed to take a picture of LVT management in current clinical practice. The survey covered diagnostic, therapeutic, and prophylactic issues and was completed by 104 European cardiac centers. Most of them (59%) were university or tertiary centers. The survey showed anterior apical a-/dyskinesia, large MI, spontaneous echo-contrast, late presentation with delayed PCI, and TIMI flow 0-1 as the most important perceived risk factors for LVT formation. Serial ultrasound imaging is the most used tool to diagnose LVT (88% of the centers), with contrast-enhanced ultrasound and cardiac MR performed in case of poor apex visualization or spontaneous echo-contrast. One third (34%) of the centers uses prophylactic anticoagulation to prevent LVT formation. In the presence of LVT, low molecular weight heparin is the most used in-hospital therapy. At discharge, vitamin K antagonist and direct oral anticoagulants are used in 67 and 32% of the cases, respectively. Triple antithrombotic therapy with aspirin plus clopidogrel and VKA is the most used strategy at discharge (55%), whereas a single antiplatelet therapy is preferred only in the case of moderate-to-high risk of bleeding. To assess LVT total regression, half of the centers use contrast-enhanced ultrasound and/or cardiac-MR. The duration of anticoagulation is usually 3-6months (55%), with long-term prolongation in case of LVT persistence or recurrence. The survey has depicted for the first time the current real-world management of this neglected topic and has highlighted several grey zones that are still present and not supported by evidence.

Association between inflammation and left ventricular thrombus formation following ST-elevation myocardial infarction

Abstract Background Current evidence suggests a link between the inflammatory state and left ventricular thrombus (LVT) formation following ST-elevation myocardial infarction (STEMI). However, a comprehensive study investigating the association between inflammatory biomarkers and LVT diagnosed by cardiac magnetic resonance (CMR) is lacking. Purpose The present study aimed to investigate the association of biochemical markers of inflammation with LVT as assessed by CMR imaging among patients with STEMI. Methods We studied 309 patients with acute STEMI treated with primary percutaneous coronary intervention (pPCI) from the prospective MARINA-STEMI cohort study. Concentrations of high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), white blood cell count (WBCc), fibrinogen and D-dimer were measured two days after STEMI. Infarct characteristics and presence of LVT were assessed with the use of contrast-enhanced CMR at a median of 4 (interquartile range [IQR] 3–5) days after pPCI. Results In total, 309 STEMI patients (18% female) with a median age of 57 (IQR 52–65) years were included. An LVT was observed in 8% (n=24) of the overall cohort and in 15% of patients with an anterior STEMI. Hs-CRP (OR: 2.16, 95% CI: 1.54–3.02, p<0.001), IL-6 (OR: 2.38, 95% CI: 1.48–3.81, p<0.001) and fibrinogen levels (OR: 2.05, 95% CI: 1.40–3.00, p<0.001) were significantly associated with presence of LVT. Among all assessed inflammatory biomarkers, only hs-CRP was independently associated with LVT after adjustment for markers of inflammation and CMR parameters (OR: 1.77, 95% CI: 1.21–2.59, p=0.004). Conclusion In patients with STEMI treated with pPCI, inflammatory markers (hs-CRP, IL-6 and fibrinogen) are associated with the presence of LVT. However, only hs-CRP was independently associated with the occurrence of LVT, highlighting the key role of CRP as clinical risk marker for LVT formation in STEMI patients treated with pPCI. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology

Prevalence of left ventricular thrombus formation after mitral valve edge-to-edge repair

The prevalence of left ventricular (LV) thrombus formation following percutaneous mitral valve edge-to-edge repair (TMVR) with the MitraClip system is unclear. Decreased total stroke volume and perfusion of the LV apex after mitral valve repair may facilitate thrombus formation especially in the context of reduced LV function. LV thrombus may cause disabling stroke or other thromboembolic events in this elderly and multimorbid patient cohort. Analyses of the prevalence of and risk factors for left ventricular thrombus formation in patients treated with the MitraClip system due to severe mitral valve regurgitation. All discharge and follow-up transthoracic echocardiographic examinations up to 6 months of 453 consecutive patients treated with the MitraClip system were screened for the presence of LV thrombus. Prevalence of LV thrombus formation was 1.1% (5/453). Importantly, LV thrombi were exclusively found in patients with severely depressed left ventricular systolic function (LV-EF < 30%), comprising a prevalence of 4.4% in this subgroup (5/113). Importantly, two of these patients were under active DOAC therapy with Rivaroxaban and Apixaban, respectively. Apart from LV-EF, we did not identify other factors that might have facilitated LV thrombus formation. LV thrombus formation following percutaneous mitral valve repair occurred exclusively in patients with severely depressed LV-EF. As two patients developed LV thrombus despite of DOAC therapy, anticoagulation with a Vitamin K antagonist should be considered in patients with an indication for oral anticoagulation following TMVR.

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.

Association between inflammation and left ventricular thrombus formation following ST-elevation myocardial infarction

BackgroundCurrent evidence suggests a link between the inflammatory state and left ventricular (LV) thrombus formation following ST-elevation myocardial infarction (STEMI). However, a comprehensive study investigating the association between inflammatory biomarkers and LV thrombus diagnosed by cardiac magnetic resonance (CMR) is lacking. MethodsWe studied 309 patients with acute STEMI treated with primary percutaneous coronary intervention (pPCI) from the prospective MARINA-STEMI cohort study. Concentrations of high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), white blood cell count (WBCc), fibrinogen and D-dimer were measured two days after STEMI. Infarct characteristics and presence of LV thrombi were assessed with the use of contrast-enhanced CMR at a median of 4 (interquartile range [IQR] 3–5) days after pPCI. ResultsIn total, 309 STEMI patients (18% female) with a median age of 57 (IQR 52–65) years were included. A LV thrombus was observed in 8% (n = 24) of the overall cohort and in 15% of patients with an anterior STEMI. Hs-CRP (OR 2.16, 95% CI 1.54–3.02, p < 0.001), IL-6 (OR 2.38, 95% CI 1.48–3.81, p < 0.001) and fibrinogen levels (OR 2.05, 95% CI 1.40–3.00, p < 0.001) were significantly associated with presence of LV thrombus. Among all assessed inflammatory biomarkers, only hs-CRP was independently associated with LV thrombus after adjustment for markers of inflammation and CMR parameters (OR 1.77, 95% CI 1.21–2.59, p = 0.004). ConclusionIn patients with STEMI treated with pPCI, inflammatory markers (hs-CRP, IL-6 and fibrinogen) are associated with the presence of LV thrombus. However, only hs-CRP was independently associated with the occurrence of LV thrombi, highlighting the key role of CRP as clinical risk marker for LV thrombus formation in STEMI patients treated with pPCI.

Surrogates of the Left Ventricular Thrombus Resolution: A Retrospective Data Review.

The left ventricular thrombus is one of the serious complications of ischemic cardiomyopathy. In this study, we aimed to search for the independent factors to predict the resolution of left ventricular thrombus. This retrospective study included all patients with coronary artery disease, aged above 18 years old, and with the thrombus at the apical location of the left ventricle. Demographic, clinical, and echocardiographic characteristics of the patients were recorded. Major adverse cardiovascular events developed within the follow-up period were recorded. The time in the therapeutic range of each patient was calculated. The presence of left ventricular thrombus beyond 180 days despite warfarin usage was classified as persistent left ventricular thrombus. The study included 174 subjects (169 males and 5 females). The mean age of the study population was 54.5 ± 11.0 years. The number of patients in whom the left ventricular thrombus resolved with treatment in less than 180 days was 56 (32.2%). Median anticoagulation time in the study population was 252 [150-480] days and the meantime in the therapeutic range of the patients was 54 ± 19%. The time in therapeutic range value of the groups was similar (P=.593). It was found that concomitant clopidogrel use (P=.003) and left ventricular thrombus area (P < .001) were the independent predictors of left ventricular thrombus resolution within less than 180 days in the logistic regression analysis. Concomitant use of clopidogrel was found to be associated with left ventricular thrombus resolution but left ventricular thrombus size was related to left ventricular thrombus persistency. Although standard 3-6 months of anticoagulation is advised for left ventricular thrombus, considering the presence of these predictors in such patients may guide the physicians to individualize the treatment.

Surrogates of the Left Ventricular Thrombus Resolution: A Retrospective Data Review.

The left ventricular thrombus is one of the serious complications of ischemic cardiomyopathy. In this study, we aimed to search for the independent factors to predict the resolution of left ventricular thrombus.This retrospective study included all patients with coronary artery disease, aged above 18 years old, and with the thrombus at the apical location of the left ventricle. Demographic, clinical, and echocardiographic characteristics of the patients were recorded. Major adverse cardiovascular events developed within the follow-up period were recorded. The time in the therapeutic range of each patient was calculated. The presence of left ventricular thrombus beyond 180 days despite warfarin usage was classified as persistent left ventricular thrombus.The study included 174 subjects (169 males and 5 females). The mean age of the study population was 54.5 ± 11.0 years. The number of patients in whom the left ventricular thrombus resolved with treatment in less than 180 days was 56 (32.2%). Median anticoagulation time in the study population was 252 [150-480] days and the meantime in the therapeutic range of the patients was 54 ± 19%. The time in therapeutic range value of the groups was similar (P=.593). It was found that concomitant clopidogrel use (P=.003) and left ventricular thrombus area (P < .001) were the independent predictors of left ventricular thrombus resolution within less than 180 days in the logistic regression analysis.Concomitant use of clopidogrel was found to be associated with left ventricular thrombus resolution but left ventricular thrombus size was related to left ventricular thrombus persistency. Although standard 3-6 months of anticoagulation is advised for left ventricular thrombus, considering the presence of these predictors in such patients may guide the physicians to individualize the treatment.

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 17234: Cisplatin Induced Coronary Artery Atherosclerosis Leading To St-elevation Myocardial Infarction: A Case Report

Introduction: Cisplatin-based chemotherapeutic regimen (CBCR) is known for increasing risk of venous thromboembolic (TE) disease. We report a unique case of STEMI associated with CBCR which we believe was caused by coronary artery thrombosis. Case description: A 31-yo man with a past history of germ cell tumor presented with chest pain radiating to back and left arm. It started this morning and intensity did not worsen with exertion. He denied any dyspnea, diaphoresis or palpitations. He was non-smoker and non-obese. He denied any family history of premature coronary artery disease. He had undergone unilateral orchiectomy a year ago, and was currently receiving chemotherapy with bleomycin, etoposide and cisplatin; the last dose of his 3 rd cycle was given the day before. EKG showed ST elevation in leads I, aVL, V4 and V5. Troponin I was high to 6.9 ng/ml (ULN 0.045 ng/ml). He received intravenous infusion of thrombolytic. An angiogram done the next day showed moderate mid-LAD disease with residual clot. A CT scan and an echocardiogram later showed left ventricular thrombus (LVT). He was kept on therapeutic enoxaparin along with aspirin. Follow up echocardiogram showed resolution of the thrombus. His chemotherapy was stopped, and he has been kept on active surveillance since then. Discussion: Most cases of CBCR-associated myocardial infarction that have been reported have been seen in the older population with other risk factors for coronary artery disease. Cases where angiographic data was available, coronary artery vasospasm appeared to be the culprit rather than a true plaque rupture. While the presence of LVT raises possibility of thromboembolism to coronaries causing MI, the angiographic findings support accelerated plaque formation to be the cause of infarction. In earlier reports, elevated pre-treatment level of von Willebrand factor has been postulated to have some role in the disease pathogenesis. Other possible mechanisms for pathogenesis include endothelial cell damage, platelet activation, and imbalance between thromboxane-prostacyclin levels. This case emphasizes the need to keep cardiac etiologies of chest pain in the differential when evaluating patients on CBCR as timely intervention is life saving and prevent morbidity.

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.

Value of the platelet-to-lymphocyte ratio in the prediction of left ventricular thrombus in anterior ST-elevation myocardial infarction with left ventricular dysfunction

BackgroundThe predictors of left ventricular thrombus (LVT) formation are not well defined in the contemporary era, especially in those patients at high risk. We aimed to evaluate whether the platelet/lymphocyte ratio (PLR) is valuable in the determination of LVT formation in patients with anterior ST-elevation myocardial infarction (STEMI) and left ventricular (LV) dysfunction.MethodsThe LVT group (n = 46) was identified from anterior STEMI patients with LV dysfunction who were treated with primary percutaneous coronary intervention (PCI) from January 2017 to December 2019 at the China-Japan Union Hospital of Jilin University. The no-LVT group (n = 92) were also selected from the same batch of patients and were age- and sex-matched to the patients with LVT. The PLR was determined at admission and was calculated as the ratio of the platelet count to the lymphocyte count using the complete blood count. The presence of LVT was determined by echocardiography.ResultsThe PLR were significantly higher in patients with LVT than in no-LVT group (p = 0.001). In a receiver operator characteristic curve (ROC) analysis, using a cut-off value of 118.07 (AUC 0.673, 95% CI: 0.574–0.771, P = 0.001), the PLR could independently predict the occurrence of LVT. Multivariate analysis showed that an increased PLR (OR = 1.011, 95% CI: 1.004–1.018, P = 0.002), the presence of a left ventricular aneurysm (OR = 46.350, 95% CI: 5.659–379.615, P < 0.001) and increased DTBT (OR = 1.005, 95% CI: 1.001–1.009, P = 0.012) were independent predictors of LVT formation.ConclusionsIn acute anterior STEMI patients with LV dysfunction, an increased PLR and DTBT and the presence of an LV aneurysm were independent predictors of LVT formation. A larger prospective study is warranted to evaluate this result.Trial registrationThis study was registered (May 4, 2019) on Chinese Clinical Trial Registry (ChiCTR-DDD-17011214).

Understanding risk factors and predictors for stroke subtypes in the ENDURANCE trials

Stroke is a devastating morbidity associated with left ventricular assist device (LVAD) support. We report a comprehensive analysis of stroke subtypes in the ENDURANCE destination therapy (DT) and ENDURANCE Supplemental (DT2) trials. Patients in the combined HeartWare LVAD (HVAD) cohorts of the DT and DT2 trials were included. Neurologic events included ischemic stroke (ischemic cerebrovascular accident [ICVA]), hemorrhagic stroke (hemorrhagic cerebrovascular accident [HCVA]), and transient ischemic attack (TIA). Peri-operative strokes were defined as occurring within 2 weeks of the implant. A total of 604 patients received an HVAD in the DT (n = 296) and DT2 (n = 308) trials. Over 2 years, 178 (29.5%) had at least 1 cerebrovascular accident (CVA). Forty-four (7.3%) had HCVAs, 116 (19.2%) had ICVAs, and 44 (7.3%) had TIAs. Thirty (5.0%) had peri-operative stroke. In multivariable analysis, sub-therapeutic international normalized ratio (INR) values were independently associated with peri-operative stroke. Supra- and/or sub-therapeutic INR values, peripheral vascular disease, and presence of left ventricular thrombus were independently associated with ICVA. No aspirin and supra- and/or sub-therapeutic INR values were independently associated with TIA. No aspirin, supra- and/or sub-therapeutic INR values, and prior stroke and/or TIA were associated with HCVA. In further analysis, mean arterial pressure (MAP) was higher in the ICVA (86.8mmHg, p = 0.0024) and TIA (88.8mmHg, p<0.0001) groups, but not in HCVA, than in the No-CVA group (81.4mmHg). Time in therapeutic range for INR was 65.3% for the No-CVA group, 62.9% (p = 0.59) for HCVA, 65.1% (p = 0.97) for ICVA, and 63.2% (p = 0.62) for TIA. Supra- and sub-therapeutic INR values at the time of CVA were associated with all stroke subtypes >14 days post-implant. MAP was higher among those with ICVA and TIA but not with HCVA compared to without CVA. Our study demonstrates the challenges of anti-thrombotic therapy and blood pressure management in LVAD population.

The prevalence of left ventricular thrombus among patients with low ejection fraction by trans-thoracic echocardiography.

Background and objectives:Ejection fraction (EF) is a measurement of heart function that reflects the portion of pumped out blood from the filled left ventricle per each heartbeat. The current study aimed to investigate the prevalence of left ventricular thrombus in patients with EF lower than 35% by using Transthoracic Echocardiography (TTE).Methods:In this prospective study, 82 cardiac patients underwent TTE procedure in order to assess the presence of left ventricular thrombus (LVT) from January 1st to December 31st 2017 at the Military Cardiac Centre in Sana’a, Yemen.Results:Out of 82 patients enrolled in this study, the mean age was 49.13 ± 14.8 years and 87.8% were male. The mean of EF was 31.16% and LVT was found in 6.1%. The spontaneous contrast was seen in 25.6% of patients indicating strong relationship with low EF (p < 0.001). Among patients with low EF, ischemic heart disease (IHD) was identified in 50%, hypertension in 30.5%, diabetes mellitus (DM) type 2 in 23.2%, and hyperlipidemia 12.2%. Exactly 80% of LVT were detected in IHD patients with dilated cardiomyopathy (DCMP) and 80% of detected LVT were apical in site.Conclusion:Cardiac patients with low ejection fraction developed left ventricular thrombosis, and most of the affected patients were ischemic heart disease with dilated cardiomyopathy. Interestingly, spontaneous contrast was found high significantly in these patients, which may reflect the continuous process of thrombus formation.

332 Echocardiographic Wall Motion Predictors of Apical Left Ventricular Thrombus Formation

Left ventricular thrombus (LVT) after anterior ST elevation myocardial infarction (aSTEMI) almost usually forms in the left ventricular (LV) apex, suggesting that apical regional wall motion abnormalities (RWMA) are fundamental in its pathogenesis. We sought to evaluate the role of severe RWMA in LVT formation after aSTEMI. 27 consecutive patients with LVT on inpatient transthoracic echocardiography (TTE) imaging after aSTEMI between January 2010 and September 2017 were retrospectively identified. Cases were matched by age and sex to 27 controls. TTE images for all patients were assessed by a blinded examiner and all 17 LV segments were graded to detect presence of severe RWMA (defined as akinetic, dyskinetic or aneurysmal LV segments). Results were analysed using univariate analysis and reported as odds ratios (OR) with 95% confidence intervals (CI). Severe RWMA in the mid anteroseptal (OR=7.19, CI=1.95-26.51, p=0.003) and mid anterior (OR=5.34, CI=1.45-19.64, p=0.012) segments were associated with LVT. Although all cases had apical segment RWMAs, severe RWMA in the apical septal (OR=1.56, CI=0.24-10.19, p=0.64), apical lateral (OR=1, CI=0.33-3.02, p=1), apical anterior (OR=1.82, CI=0.39-8.51, p=0.45), apical inferior (OR=0.47, CI=0.16-1.40, p=0.18), and apical cap (OR=1.18, CI=0.38-3.60, p=0.78) were not associated with LVT. While apical RWMA was present in all patients with LVT, only severe RWMA in the mid anteroseptal and mid anterior segments were associated with presence of LVT. This suggests that although apical RWMA are necessary for LVT formation, larger infarct size with mid segment extension are more predictive of LVT.

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.

Left Ventricular Thrombus After Primary PCI for ST-Elevation Myocardial Infarction: 1-Year Clinical Outcomes

BackgroundLeft ventricular thrombus formation is a complication of acute myocardial infarction. However, the incidence and risk of systemic thromboembolism in the era of primary angioplasty for ST elevation myocardial infarction (STEMI) is unclear. This study aims to determine clinical outcomes in patients with STEMI treated with primary angioplasty and left ventricular thrombus at 1 year. MethodsPatients who underwent primary angioplasty for STEMI and had a transthoracic echocardiogram were recruited. The primary endpoint was a composite of all-cause mortality, stroke, and systemic thromboembolism at 1 year. For the primary endpoint, the difference between the presence and absence of left ventricular thrombus was compared using a logistic regression, adjusting for minimization variables including age, diabetes mellitus, hypertension, and previous stroke. ResultsOf 2608 patients who underwent primary angioplasty for STEMI, 1645 (63%) patients had a transthoracic echocardiogram performed during the index hospital admission. Forty patients (2.4%) had evidence of left ventricular thrombus on transthoracic echocardiography. Patients with left ventricular thrombus were more likely to develop atrial fibrillation in the immediate postinfarction period (6 [15%] vs 87 [5.4%], P = 0.025). At 1 year, the primary endpoint occurred in 4 (10%) patients with left ventricular thrombus and 146 (9.1%) who did not (logistic regression hazard ratio 0.79, 95% confidence interval 0.23-2.70). ConclusionsIn the contemporary era of mechanical reperfusion for STEMI, echocardiographic detection of left ventricular thrombus was observed in <3% patients. The presence of left ventricular thrombus was not associated with an increased risk of systemic thromboembolism.

Left ventricular thrombus formation in myocardial infarction is associated with altered left ventricular blood flow energetics.

AimsThe main aim of this study was to characterize changes in the left ventricular (LV) blood flow kinetic energy (KE) using four-dimensional (4D) flow cardiovascular magnetic resonance imaging (CMR) in patients with myocardial infarction (MI) with/without LV thrombus (LVT).Methods and resultsThis is a prospective cohort study of 108 subjects [controls = 40, MI patients without LVT (LVT− = 36), and MI patients with LVT (LVT+ = 32)]. All underwent CMR including whole-heart 4D flow. LV blood flow KE wall calculated using the formula: , where ρ = density, V = volume, v = velocity, and was indexed to LV end-diastolic volume. Patient with MI had significantly lower LV KE components than controls (P < 0.05). LVT+ and LVT− patients had comparable infarct size and apical regional wall motion score (P > 0.05). The relative drop in A-wave KE from mid-ventricle to apex and the proportion of in-plane KE were higher in patients with LVT+ compared with LVT− (87 ± 9% vs. 78 ± 14%, P = 0.02; 40 ± 5% vs. 36 ± 7%, P = 0.04, respectively). The time difference of peak E-wave KE demonstrated a significant rise between the two groups (LVT−: 38 ± 38 ms vs. LVT+: 62 ± 56 ms, P = 0.04). In logistic-regression, the relative drop in A-wave KE (beta = 11.5, P = 0.002) demonstrated the strongest association with LVT.ConclusionPatients with MI have reduced global LV flow KE. Additionally, MI patients with LVT have significantly reduced and delayed wash-in of the LV. The relative drop of distal intra-ventricular A-wave KE, which represents the distal late-diastolic wash-in of the LV, is most strongly associated with the presence of LVT.