Resolution Of Left Ventricular Thrombus Research Articles

Efficacy of direct oral anticoagulants vs. warfarin in left ventricular thrombus in myocardial infarction: systematic review and meta-analysis.

Current recommendations for antithrombotic strategies in left ventricular (LV) thrombus following myocardial infarction (MI) remain uncertain. This study aimed to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to warfarin in LV thrombus following MI. A systematic search using four databases, including PubMed, Embase, Web of Science, and Cochrane CENTRAL, was conducted from inception to 8 July 2024, without language restrictions. The inclusion criteria were studies that included patients with LV thrombus following MI and compared the efficacy or safety of DOACs and warfarin. There were 11 studies (3 randomized and 8 nonrandomized) included in this meta-analysis, involving 14 927 participants. We used a random-effects model for this meta-analysis. DOACs were associated with higher thrombus resolution than warfarin, with a risk ratio (RR) of 1.07 [95% confidence interval (CI) 1.00-1.15], P = 0.04. Similarly, DOACs were associated with a lower rate of stroke and systemic embolism, with an RR of 0.84 (95% CI 0.78-0.90), P < 0.01. DOACs also marginally reduced the rate of major bleeding compared with warfarin, with an RR of 0.87 (95% CI 0.75-1.00), P = 0.05. DOACs were associated with higher rates of LV thrombus resolution, lower rates of stroke/systemic embolism, and marginally reduced major and bleeding events compared with warfarin in patients with LV thrombus following acute MI. Therefore, DOACs may be a reasonable alternative to warfarin in this setting.

Direct oral anticoagulants or warfarin in patients with left ventricular thrombus: a meta-analysis of randomized clinical trials

Abstract Background/Introduction There are limited randomized controlled trials (RCTs) data on the use of direct oral anticoagulants (DOAC) versus warfarin in patients with left ventricular (LV) thrombus. Current AHA and ESC guidelines recommend oral anti-coagulants (either DOAC or warfarin) for 3 to 6 months without any preference. Purpose We aimed to compare outcomes with DOACs versus warfarin in patients with LV thrombus. Methods A comprehensive literature search was performed from inception to 02/01/2024 of the PubMed database. RCTs of adult patients comparing DOAC to warfarin were evaluated for mortality, major bleeding, stroke, and LV thrombus resolution. Meta-analytic Odds ratio (OR) with 95% confidence intervals (CI) were calculated using DerSimonian-Laird method. Results From 100 studies, four RCTs with 188 subjects (95 DOAC and 93 warfarin) were included with mean age of 53.4 years, 69.5% males, and mean follow up 5.03 months. There was no difference in mortality (OR= 0.67 [95% CI 0.15-3.06]; p=0.60; I2=0%; 3 trials), stroke (OR= 0.46 [95% CI 0.09-2.44]; p=0.37; I2=0%; 4 trials), major bleeding (OR= 0.43 [95% CI 0.12-1.55]; p=0.20; I2=0%; 4 trials), and LV thrombus resolution (OR= 1.33 [95% CI 0.45-3.95]; p=0.61; I2=0%; 2 trials) with use of DOAC compared to warfarin (Figure Panel A to D). Overall, there was no evidence of publication bias using either funnel plot or eggers test (p &amp;gt; 0.05). Conclusions In this meta-analysis of 4 RCTs, there was similar efficacy and safety of DOAC and warfarin in patients with LV thrombus. However, the evidence is limited by small sample size with lesser precision in the estimates. Future large-scale trials are needed to confirm these findings.

Impact of coronary revascularization on clinical outcomes of post-acute myocardial infarction patients with left ventricular thrombus

Abstract Background Left ventricular thrombus (LVT) is an uncommon, but dangerous complication seen in post-acute myocardial infarction (AMI). With advances in percutaneous coronary intervention (PCI) techniques, the incidence of post-AMI LVT has declined in the contemporary era. However, a minority of patients do not undergo coronary revascularisation due to medical contraindications or patient preference. This study aimed to evaluate the clinical characteristics and outcomes of post-AMI LVT patients treated with and without coronary revascularisation. Methods This was a retrospective study of 263 consecutive post-AMI patients diagnosed with LVT from November 2012 to January 2021, retrieved from a echocardiography database. Patients were stratified by the presence or absence of revascularisation treatment. Baseline clinical characteristics, treatment and outcomes data were collected and analysed. Results The median follow-up duration was 2.9 years (IQR: 0.9 – 4.7). A majority of post-AMI LVT patients underwent revascularisation via PCI (71.5%, n = 188), CABG (4.2%, n = 11) or thrombolysis (0.4%, n = 1). Unrevascularised patients (24.0%, n = 63) were older (p &amp;lt;0.001), more likely to be female (p &amp;lt;0.001), and had more co-morbidities such as previous stroke (p &amp;lt;0.001), heart failure (p = 0.001), chronic kidney disease (p = 0.020), and malignancy (p = 0.021). More unrevascularised patient had NSTEMI (p &amp;lt; 0.001), and significantly fewer were treated with triple therapy (p &amp;lt; 0.001). Incidence of LVT resolution was lower (p &amp;lt; 0.001) while all-cause mortality was higher (p &amp;lt; 0.001) for unrevascularised patients on univariate survival analyses. On multivariable Cox regression, revascularisation status was not an independent predictor of LVT resolution, bleeding, stroke, or all-cause mortality outcomes. Conclusion While unrevascularised post-AMI LVT patients had poorer outcomes compared to revascularised patients overall, revascularisation status itself was not independently associated with poorer clinical outcomes. Optimising medical therapy such as triple therapy remains a key treatment goal for post-AMI LVT patients.

Evolution of Left Ventricular Thrombus on Serial Cardiovascular Magnetic Resonance Imaging.

Current management of left ventricular (LV) thrombus relies on limited, non-contemporary, echocardiography-based studies. Data on LV thrombus evolution and the associated embolic risk are scarce. We aimed to describe the evolution of LV thrombus on serial cardiovascular magnetic resonance imaging (CMR) - the current reference standard for the detection of LV thrombus, and identify correlates of no resolution and the embolic risk associated with resolution status. We conducted a retrospective cohort study of 107 consecutive patients with LV thrombus who had 213 serial CMRs at a median of 255 days after the index CMR. Of these, 97.2% were anticoagulated. At 3 months after detection by CMR, 75% (47/63) had no resolution of LV thrombus; at 6 months, 53% (35/66) had no resolution; and at 12 months, 37% (23/63) had no resolution. Correlates of no resolution at 6 months included a history of myocardial infarction, LV aneurysm, ischemic etiology of cardiomyopathy, and larger thrombus volume. Recurrence of LV thrombus was rare at 5.3%. On survival analysis using the landmark analysis method, embolic events often occurred beyond 6 months, more frequently in patients with unresolved LV thrombus. Our findings challenge previous literature by demonstrating a lower rate of resolution of LV thrombus and substantial embolic risk beyond 6 months associated with unresolved LV thrombus on serial CMR. Our findings advocate for extended anticoagulation, particularly in patients with markers associated with no resolution. These findings have important implications for clinical practice and research into managing patients with LV thrombus.

Meta-Analysis of the Safety and Efficacy of Direct Oral Anticoagulants for the Treatment of Left Ventricular Thrombus.

Literature on the preferred anticoagulant for treating left ventricular thrombus (LVT) is lacking. Thus, our objective was to compare the efficacy of DOACs versus warfarin in treating LVT. Databases were searched for RCTs and adjusted observational studies that compared DOAC versus warfarin through March 2024. The primary efficacy outcomes of interest were LVT resolution, systemic embolism, composite of stroke, and TIA. The primary safety outcomes encompassed all-cause mortality and bleeding events. Our meta-analysis including 31 studies demonstrated that DOAC use was associated with higher odds of thrombus resolution (OR: 1.08, 95% CI: 0.86-1.31, p: 0.46). A statistically significant reduction in the risk of stroke/TIA was observed in the DOAC group versus the warfarin group (OR: 0.65, 95% CI: 0.48-0.89, p: 0.007). Furthermore, statistically significant reduced risks of all-cause mortality (OR: 0.68, 95% CI: 0.47-0.98, p: 0.04) and bleeding events (OR: 0.70, 95% CI: 0.55-0.89, p: 0.004) were observed with DOAC use as compared to warfarin use. Compared to VKAs, DOACs are noninferior as the anticoagulant of choice for LVT treatment. However, further studies are warranted to confirm these findings.

Factors predicting resolution of left ventricular thrombus in different time windows after myocardial infarction

BackgroundLeft ventricular thrombus (LVT) is a serious complication after myocardial infarction. However, due to its asymptomatic nature, early detection is challenging. We aimed to explore the differences in clinical correlates of LVT found in acute to subacute and chronic phases of myocardial infarction.MethodsWe collected data from 153 patients who were diagnosed with LVT after myocardial infarction at the Affiliated Hospital of Qingdao University from January 2013 to December 2022. Baseline information, inflammatory markers, transthoracic echocardiograph (TTE) data and other clinical correlates were collected. Patients were categorized into acute to subacute phase group (< 30 days) and chronic phase group (30 days and after) according to the time at which echocardiograph was performed. The resolution of thrombus within 90 days is regarded as the primary endpoint event. We fitted logistic regression models to relating clinical correlates with phase-specific thrombus resolution.ResultsFor acute to subacute phase thrombus patients: C-reactive protein levels (OR: 0.95, 95% CI: 0.918–0.983, p = 0.003) were significantly associated with thrombus resolution. For chronic phase thrombus patients: anticoagulant treatment was associated with 5.717-fold odds of thrombus resolution (OR: 5.717, 95% CI: 1.543–21.18, p = 0.009).ConclusionsHigher levels of CRP were associated with lower likelihood of LVT resolution in acute phase myocardial infarction; Anticoagulant therapy is still needed for thrombus in the chronic stage of myocardial infarction.

Left ventricular reverse remodelling as a promising strategy for resolving left ventricular thrombus.

Recent years, several studies have suggested that abnormal baseline left ventricular (LV) function and structure are associated with left ventricular thrombus (LVT) formation. Despite this, most studies have given less attention to the potential role of left ventricular reverse remodelling (LVRR), that is, the improvement of LV function and structure, in resolving LVT. In this study, we aim to investigate the clinical characteristics, prognosis, and LVT resolution in patients with LVRR. This is a retrospective study conducted at The First Affiliated Hospital of Dalian Medical University. Our cohort consists of patients diagnosed with LVT between 1 November 2015 and 31 May 2020. Enrolled patients were categorized into two groups: LVRR and Failure of LVRR. The primary endpoints included LVT resolution and embolic events. A total of 84 patients were included in the study, with 59 patients in the LVRR group and 25 patients in the Failure of LVRR group. In our study, patients in the LVRR group experienced higher incidence of LVT resolution and a lower risk of embolic events. Multivariate logistic analysis revealed that Failure of LVRR was the only independent negative predictor for LVT resolution and positive predictor for embolic events. Patients with LVRR experience higher incidence of LVT resolution and have lower risk of embolic events, highlighting the significance of identifying and mitigating risk factors that contribute to abnormal LV function and structure in management of patients with LVT.

Non-vitamin K oral anticoagulants versus warfarin for the treatment of left ventricular thrombus.

Left ventricular thrombus (LVT) is associated with significant morbidity and mortality. Conventional treatment comprises warfarin-mediated anticoagulation; it is unclear whether non-vitamin K oral anticoagulants (NOACs) exhibit comparable efficacy and safety. Limited data are available for Asian patients. This study compared NOACs with warfarin in terms of clinical efficacy and safety for managing LVT. Clinical and echocardiographic records were retrieved for all adult patients with echocardiography-confirmed LVT at a major regional centre in Hong Kong from January 2011 to January 2020. Discontinuation of anticoagulation by 1 year was recorded. Outcomes were compared between patients receiving NOACs and those receiving warfarin. Primary outcomes were cumulative mortality and net adverse clinical events (NACEs). Secondary outcomes were complete LVT resolution and percentage reduction in LVT size at 3 months. Forty-three patients were included; 28 received warfarin and 15 received NOACs, with follow-up periods (mean ± standard deviation) of 20 ± 12 months and 22 ± 9 months, respectively (P=0.522). Use of NOACs was associated with significantly lower NACE risk (hazard ratio [HR]=0.111, 95% confidence interval [CI]=0.012-0.994; P=0.049) and a tendency towards lower cumulative mortality (HR=0.184, 95% CI=0.032-1.059; P=0.058). There were no significant differences in secondary outcomes. Considering LVT resolution, discontinuation of anticoagulation by 1 year was not significantly associated with different outcomes. Non-vitamin K oral anticoagulants may be an efficacious and safe alternative to warfarin for LVT management. Future studies should explore the safety and efficacy of anticoagulation discontinuation by 1 year as an overall strategy.

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

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

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

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

Clinical profile and prognosis of elderly patients with left ventricular thrombus after anticoagulation

BackgroundContemporary data regarding the clinical characteristics and prognosis of left ventricular thrombus (LVT) in older adults (aged ≥ 65 years old) are lacking. In this study, we characterized elderly patients with LVT (aged ≥ 65 years old) and investigated the long-term prognosis in this highly vulnerable patient population.MethodsThis single-center, retrospective study was conducted from January 2017 to December 2022. Patients with a reported LVT were assessed primarily by transthoracic echocardiography (TEE) and classified into two groups: elderly LVT groups and younger LVT groups. All patients were treated with anticoagulant treatment. Major adverse cardiovascular event (MACE) was defined as the composite of all-cause mortality, systemic embolism, and rehospitalization for cardiovascular events. Survival analyses were performed with the Kaplan-Meier method and Cox proportional-hazard model.ResultsA total of 315 eligible patients were included. Compared to the younger LVT group (n = 171), the elderly LVT group (n = 144) had a lower proportion of males and lower serum creatinine clearance, as well as a higher level of NT-proBNP, and a higher rate of history of systemic embolism. LVT resolution occurred in 59.7% and 69.0% of patients in the elderly LVT group and younger LVT group, respectively, with no significant difference (adjusted HR, 0.97; 95% CI, 0.74–1.28; P = 0.836). Yet, elderly patients with LVT, had higher prevalence rates of MACE (adjusted HR, 1.52; 95% CI, 1.10–2.11; P = 0.012), systemic embolism (adjusted HR, 2.81; 95% CI, 1.20–6.59; P = 0.017) and all-cause mortality (adjusted HR, 2.20; 95% CI, 1.29–3.74; P = 0.004) compared with younger patients with LVT. After adjusting for mortality in the Fine–Gray model, similar results were observed. Additionally, patients treated with different anticoagulation therapies (DOACs vs. warfarin) achieved a similar improvement in prognosis (P > 0.05) or LVT resolution (P > 0.05) in elderly patients with LVT.ConclusionsOur results found that elderly patients experiencing LVT have a poor prognosis compared with the younger ones. Clinical prognosis in elderly patients did not significantly differ with the type of anticoagulant used. With aging societies worldwide, further evidence of antithrombotic therapy in elderly individuals with LVT is necessary.

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&amp;lt;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.

Assessment of Left Ventricular Thrombus Using Cardiac Computed Tomography

Left ventricular thrombus (LVT) can be missed on transthoracic echocardiogram and although cardiac magnetic resonance imaging (cMRI) is the gold standard of assessment, access to cMRI is limited. Cardiac computed tomography (CCT) has been suggested as an alternative. This study prospectively investigated the optimal CT acquisition time to assess for the presence of LVT. Patients admitted to Auckland City Hospital, New Zealand, found to have LVT and no contraindication to CCT were recruited. The CCTs were performed timed at peak contrast enhancement arterial-phase (CTA), 60–70 seconds delay venous-phase (CTV), and delay multi-energy CT (CTD). The study was supported by the Greenlane Cardiovascular Fund. Eleven patients were recruited over a 30-month period. The mean age was 50±13 years and 73% were male. An LVT was confirmed on CCT in 10 patients (91%). One patient with LVT on TTE did not have LVT on CCT and cMRI. Transthoracic echocardiography (TTE) failed to detect 18% of LVT. Amongst the three CT protocols, LVT was best detected on CTV when the thrombus and adjacent myocardium demonstrated good tissue differentiation, allowing for improved thrombus detection. Although CTD was able to detect the presence of an LVT, there was a reduction in image quality. Resolution of LVT was seen in 78% of patients at 3 months and all LVT had resolved by 6 months. The mean radiation dose for CTA was 2.6±2.4 mSv, 1.5±0.9 mSv for CTV, and 3.6±1.8 mSv for CTD. There was improved tissue separation between the adjacent myocardium and LVT and thereby improved LVT detection using venous-phase CT (CTV).

Clinical Outcome After Left Ventricular Thrombus Resolution: Who Needs Long-Term or Lifetime Use of Anticoagulants?

Background Patients with left ventricular thrombus (LVT) resolution can have LVT recurrence and risk for thromboembolism. However, these outcomes after LVT resolution are not well known. We aimed to assess the prevalence, risk factors, and clinical outcomes for LVT recurrence in patients with LVT resolution to inform follow-up and treatment. Methods and Results Patients with LVT resolution were identified retrospectively from a large echocardiography database between January 2009 and May 2022. Participants had echocardiograms at 3 time points, including baseline at LVT diagnosis, at LVT resolution, and a follow-up for identification of LVT recurrence. The cumulative LVT recurrence rate was estimated by the Kaplan-Meier method, and predictors of LVT recurrence were evaluated using Cox regression analysis. Among 115 patients with LVT resolution, 28 (24.3%) had LVT recurrence at a median follow-up of 1.2 (0.5-2.8) years. LV aneurysm (hazard ratio [HR], 2.59 [95% CI, 1.20-5.58], P=0.015) and anticoagulant use (HR, 0.12 [95% CI, 0.04-0.41], P=0.001) were predictors of LVT recurrence on multivariable analysis. Patients with an LV aneurysm who did not receive any anticoagulation demonstrated an LVT recurrence rate of 69.5%, whereas those without an LV aneurysm who received anticoagulation had a recurrence rate of 0%. Patients with LVT recurrence had a higher incidence of an embolic event (10.7% versus 1.1%, P=0.016). Conclusions LVT recurrence after LVT resolution is common, especially in those with an LV aneurysm, and is associated with a higher embolic risk. Continued anticoagulation is protective against LVT recurrence, although bleeding risk needs to be considered. These findings can inform follow-up and treatment of patients with documented LVT resolution.

Factors influencing left ventricular thrombus resolution and its significance on clinical outcomes.

A left ventricular thrombus (LVT) is not uncommon in patients with impaired LV systolic function. However, the treatment strategy for LVT has not yet been fully established. We aimed to identify the factors influencing LVT resolution and the significance of LVT resolution on clinical outcomes. We retrospectively investigated patients diagnosed with LVT with left ventricular ejection fraction (LVEF)<50% on transthoracic echocardiography from January 2010 to July 2021 in a single tertiary centre. LVT resolution was monitored through serial follow-up transthoracic echocardiography. The primary clinical outcome was a composite of all-cause death, stroke, transient ischaemic attack, and arterial thromboembolic events. LVT recurrence was also evaluated in patients with LVT resolution. There were 212 patients diagnosed with LVT (mean age, 60.5±14.0years; male, 82.5%). The mean LVEF was 33.1±10.9%, and 71.7% of patients were diagnosed with ischaemic cardiomyopathy. Most patients were treated with vitamin K antagonists (86.7%), and 28 patients (13.2%) were treated with direct oral anticoagulants or low molecular weight heparin. LVT resolution was observed in 179 patients (84.4%). LVEF improvement failure within 6months was a significant factor hindering LVT resolution (hazard ratio, HR: 0.52, 95% confidence interval, CI: 0.31-0.85, P=0.010). During a median 4.0years of follow-up (interquartile range, IQR: 1.9 to 7.3years), 32 patients (15.1%) experienced primary outcomes (18 all-cause deaths, 15 strokes, and 3 arterial thromboembolisms) and 20 patients (11.2%) experienced LVT recurrence after LVT resolution. LVT resolution was independently associated with a lower risk for primary outcomes (HR: 0.45, 95% CI: 0.21-0.98, P=0.045). In the patients with resolved LVT, discontinuation or duration of anticoagulation after resolution were not significant predictors for LVT recurrence, but LVEF improvement failure at LVT resolution was associated with a significantly higher risk of LVT recurrence (HR: 3.10, 95% CI: 1.23-7.78, P=0.016). This study suggests that LVT resolution is an important predictor for favourable clinical outcomes. LVEF improvement failure interfered with LVT resolution and appeared to be a crucial factor for LVT recurrence. After LVT resolution, continuation of anticoagulation did not seem to impact LVT recurrence and the prognosis.

Left Ventricular Thrombosis: Current Perspective and Use of Direct Oral Anticoagulants

Left ventricular thrombus (LVT) is a serious risk factor for systemic embolism development. Despite the evident danger of this condition, current guidelines describe management of patients with this potentially fatal complication very briefly. LVT can complicate myocardial infarction where its incidence is around 10%, as well as various forms of cardiomyopathies and novel coronavirus infection. According to clinical guidelines vitamin K antagonists (VKAs) should be used as treatment of choice for thrombus resolution. However, experts point out that this therapy lacks necessary evidential base and bears certain difficulties because of pharmacokinetic and pharmacodynamical properties of VKAs. These drawbacks are absent in direct oral anticoagulants (DOACs), the possibility of using which in LVT is being actively studied. As for now, published results of 3 randomised clinical trials have demonstrated similar safety and efficacy profiles of DOACs and VKAs. Similarly, the majority of retrospective cohort studies did not observe significant differences between two groups, where some of them have shown superiority of DOACs especially in terms of earlier thrombus resolution. Nevertheless, some studies have found DOACs ineffective and even potentially unsafe regarding systemic embolism. Existing data does not allow to form an unambiguous conclusion about the equivalence of DOACs and VKAs for LVT resolution. Large randomised clinical trials are needed to determine efficacy and safety of such treatment in these patients.

Apixaban in Patients With Post-Myocardial Infarction Left Ventricular Thrombus: A Randomized Clinical Trial

BackgroundDirect oral anticoagulants are frequently used to treat post-myocardial infarction (MI) left ventricular thrombus (LVT). This study was conducted to evaluate the efficacy and safety of use of apixaban, compared to the standard warfarin therapy, in post-MI LVT. MethodsThis open-label, randomized controlled trial included patients with post-acute or recent anterior wall MI with transthoracic echocardiography-confirmed LVT. Patients were randomized to receive either apixaban 5 mg twice daily or warfarin to achieve an international normalized ratio of 2-3, in addition to dual antiplatelet therapy. The primary endpoint was LVT resolution at 3 months, with a noninferiority margin of 95% for apixaban compared to warfarin. The secondary endpoint was major adverse cardiovascular events (MACE) or any relevant bleeding according to the Bleeding Academic Research Consortium (BARC) classification. ResultsFifty patients were enrolled from 3 centres. The use of dual or single antiplatelet agents was similar in the 2 groups. The number of 1-, 3-, and 6-month LVT resolutions were 10 (40.0%), 19 (76.0%), and 23 (92.0%) in the apixaban group, and 14 (56%), 20 (80.0%), and 24 (96.0%) in the warfarin group, respectively, without significant differences (P < 0.036 for noninferiority at 3 months). Patients taking warfarin required longer hospital stays and more outpatient visits. Multivariate adjustment analysis revealed left ventricular aneurysm, larger baseline LVT area and lower left ventricular ejection fraction to be independent predictors of LVT persistence at 3 months. No MACE occurred in either group; 1 BARC-2 bleeding event occurred with warfarin. ConclusionsApixaban was not inferior to warfarin in the resolution of post-MI LVT.

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.

Abstract 13019: LV Thrombus With Embolic Phenomena: Identifying the Culprit

Background: Left ventricular (LV) thrombus occurs with prior myocardial infarction (MI), particularly anterior ST-elevation MI (STEMI), dilated cardiomyopathy, and prothrombotic conditions. Case: A 38-year-old female with poorly controlled type 2 diabetes mellitus presented with leg pain and dyspnea. Her left lower extremity was cold and mottled, with absent pulses in both legs. EKG revealed lateral STEMI. Emergent coronary angiogram revealed 85% proximal left circumflex stenosis and 100% stenosis of the proximal first obtuse marginal branch (not amenable to intervention due to small vessel caliber). The patient then underwent bilateral iliofemoral and popliteal embolectomy. Transthoracic echocardiogram revealed ejection fraction (EF) of 40% and a 1 x 1 cm thrombus attached to the posteromedial papillary muscle; heparin was started. The patient later developed right-sided weakness; brain MRI revealed multiple acute-subacute infarcts in the left cerebral hemisphere. Transesophageal echocardiogram was negative for patent foramen ovale or shunt. Decision-making: LV thrombus with embolic phenomena raised suspicion for underlying thrombophilia. The patient was started on warfarin and clopidogrel, with outpatient follow-up for hypercoagulability workup, which was negative. Cardiac MRI later revealed resolution of LV thrombus, and oral anticoagulation was discontinued after 3 months, and switched to aspirin. Conclusion: LV thrombus is far more common after anterior STEMI as it affects a larger area of myocardium, but it can also occur with lateral STEMI. Hypercoagulability state should be considered on the differential of LV thrombus in the setting of lateral STEMI. If hypercoagulability workup is negative, aggressive risk factor modification for coronary disease should be pursued.

Efficacy and safety of direct oral anticoagulants in the treatment of left ventricular thrombus after acute anterior myocardial infarction in patients who underwent percutaneous coronary intervention.

To explore treatment with direct oral anticoagulants (DOACs) in left ventricular thrombus (LVT) after ST-segment elevation myocardial infarction (STEMI) in patients who underwent percutaneous coronary intervention (PCI). Contemporary data regarding using DOACs for LVT after STEMI patients who underwent PCI is limited. To investigate the efficacy and safety of DOACs on treatment of LVT post STEMI and PCI. This retrospective study enrolled patients with LVT post STEMI and PCI within 1month from onset who received warfarin or DOACs at discharge. Primary endpoint was LVT resolution. Secondary endpoints were major adverse cardiovascular events (MACEs), including death, stroke, systemic embolism (SE), myocardial infarction (MI) and major or minor bleeding. A total of 128 consecutive patients were recruited, of which 72 received warfarin and 56 DOACs [48 on rivaroxaban and 8 on dabigatran]. Rate of LVT resolution was higher within 1 month in the DOAC group than warfarin (26.8% vs 11.1%; p=0.022) (Kaplan-Meier estimates, p=0.002).No significant differences were found at 3 months ( p=0.246), 6 months (p=0.201), 9 months (p=0.171) and 12 months (p=0.442). No patients treated with DOACs had major bleeding, while two patients with warfarin had upper gastrointestinal bleeding (0 vs 2 (2.8%); p=0.209). No death or SE was occurred. No significant differences on secondary endpoints were found in both the groups, including stroke, MI, minor bleeding and all bleeding events. DOACs appears to be a suitable alternative to warfarin for the management of LVT post STEMI, especially in patients who are intolerant to warfarin.