Prospective two-dimensional echocardiographic evaluation of left ventricular thrombus and embolism after acute myocardial infarction

Long-term left ventricular thrombosis resolution in patients receiving vitamin k antagonists: a multicenter observational study

Optimal duration of anticoagulant therapy for left ventricular thrombous (LVT) is unclear. The aim of this study is to evaluate effectiveness and safety of vitamin K antagonists (VKAs) up to 12 months in patients with LVT. Patients diagnosed with LVT between 2011 and 2023 and treated with VKAs until LVT resolution or up to 12 months were enrolled in a retrospective cohort study. Primary outcome included on-treatment LVT resolution, secondary outcomes acute ischemic stroke, myocardial infarction, peripheral embolism, and major and clinically relevant non-major bleedings during the 12-month follow-up. Ninety patients were included. Median age was 66 years and 78.9% were male. Mean time in therapeutic range was 61% and 32.9% of patients received VKA monotherapy, with the remaining concomitant antiplatelet treatment. The 3, 6, 12 months cumulative incidences of LVT resolution were 27% (95% confidence intervals -95%CI-, 18%-36%), 47% (95%CI 36%-57%), and 70% (95% CI 60%-79%), respectively. At Cox regression model, reduced left ventricular ejection fraction (Hazard Ratio 0.48; 95%CI 0.24-0.95) and left-ventricular aneurysms (Hazard Ratio 0.44; 95%CI 0.22-0.88) were associated with reduced LVT resolution. One patient developed an acute ischemic stroke and one an acute myocardial infarction. Two patients developed a major and four a clinically relevant non-major bleeding. Incidence of LVT resolution appeared to be higher at 12 than at 3 and 6 months of follow-up, and the rates of on-treatment acute arterial and bleeding events were low. Reduced left ventricular ejection fraction and left-ventricular aneurysm appeared to be associated with a lower rates of LVT resolution.

Left Ventricular Thrombosis in Ischemic and Non-Ischemic Cardiomyopathies: Focus on Evidence-Based Treatment

Left ventricular thrombosis (LVT) is one of the most feared complications of both ischemic and non-ischemic cardiopathy, and despite its incidence having decreased over the years (mostly due to novel reperfusion therapies in acute coronary syndromes), it is still not negligible. If transthoracic echocardiography, possibly with the adjunction of echo contrast, represents the cornerstone in LVT diagnosis, sometimes it is found to be nonconclusive and advanced cardiovascular imaging, namely cardiac magnetic resonance, needs to be performed to fully exclude intraventricular masses or to better characterize them. Vitamin K antagonists always represented the anticoagulant of choice for the treatment of LVT; however, the recent spread of direct oral anticoagulants (DOACs) pushed clinicians to adopt them also in this setting despite the absence of robust evidence in their favor. If the optimal duration of anticoagulation for the treatment of LVT in non-ischemic cardiopathy is still a matter of debate, an initial treatment of 3-6 months seems to be reasonable in the setting of ischemic cardiopathy, with possible extension according to the follow-up findings. High-quality randomized studies are strongly needed to evaluate the potential role of prophylactic anticoagulation in high-risk patients and provide conclusive evidence for the use of DOACs in LVT treatment.

Direct oral anticoagulants or warfarin in patients with left ventricular thrombus after ST-elevation myocardial infarction: a pilot trial and a prespecified meta-analysis of randomised trials

BACKGROUND

The role of direct oral anticoagulants (DOACs) in the treatment of left ventricular thrombus (LVT) after ST-elevation myocardial infarction (STEMI) remains uncertain.

AIMS

We aimed to compare the effect of rivaroxaban versus warfarin in patients with STEMI complicated by LVT.

METHODS

Adult patients with STEMI and two-dimensional transthoracic echocardiography showing LVT were assigned to rivaroxaban (15 mg once daily) or warfarin (international normalised ratio goal of 2.0-2.5) in an open-label, randomised clinical trial (RCT). A prospective pooled analysis was planned comparing DOAC- versus warfarin-based anticoagulation for the same indication. The main outcome of the RCT was complete LVT resolution at 3 months, determined by a blinded imaging core laboratory. Complete LVT resolution and bleeding were investigated in the pooled analysis.

RESULTS

A total of 50 patients (median age: 55 years, 18% females) were enrolled from June 2020 to November 2022. Three-month complete LVT resolution occurred in 19/25 (76.0%) patients assigned to rivaroxaban and 13/24 (54.2%) assigned to warfarin (relative risk [RR] 1.40, 95% confidence interval [CI]: 0.91-2.15; p=0.12) with no thrombotic or major bleeding events. Pooled analysis showed numerically better complete LVT resolution with DOACs (rivaroxaban and apixaban; 93/115 [80.8%] vs 79/112 [70.5%], RR 1.14, 95% CI: 0.98-1.32; p=0.08) and less major bleeding (2/116 [1.7%] and 9/112 [8.0%], risk difference -0.06, 95% CI: -0.12 to 0.00; p=0.05) than with warfarin.

CONCLUSIONS

Although the findings are limited by a small sample size, the results suggest that DOACs are safe with at least similar outcomes concerning LVT resolution and major bleeding compared with warfarin. (ClinicalTrials.gov: NCT05705089).

Evaluation of the efficacy and safety of rivaroxaban compared to warfarin in patients with left ventricular apical thrombus: a randomized clinical trial

INTRODUCTION

This research is one of the pioneering randomized clinical trials (RCTs) aimed at assessing the effectiveness and safety of rivaroxaban in treating left ventricular thrombus (LVT) in patients who have experienced acute coronary syndrome (ACS).

MATERIALS AND METHODS

This is a randomized, controlled, interventional, open-label study. The patients were randomly divided into warfarin and rivaroxaban groups. We performed transthoracic echocardiography at the start of the study and again after three months to measure the thrombus area in square millimeters. The morphology of the thrombus was categorized into mural and round, and the mobility was classified into immobile, semi-mobile and hypermobile. We also monitored for adverse events including bleeding, systemic embolic occurrences, rehospitalization, and major adverse cardiac events (MACE).

RESULTS

The study included fifty-two patients in the intention-to-treat analysis, with an equal split between the rivaroxaban and warfarin groups (26 patients each). The average follow-up duration was three months. The thrombus resolution rates in the rivaroxaban (76.9%) and warfarin (69.2%) groups, as well as the thrombus size reduction, did not show statistical significance between groups. All semi-mobile or hypermobile thrombi transformed into immobile and all of the round LVTs changed into a mural in both rivaroxaban and warfarin groups. No significant difference was observed in bleeding complications and rehospitalization between the two groups.

CONCLUSION

The trial demonstrated that rivaroxaban is as effective as warfarin in terms of thrombus resolution rate, reduction in thrombus size, bleeding risk, and rehospitalization rate. Our findings suggest that rivaroxaban is a viable alternative to warfarin for managing left ventricular thrombus.

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

INTRODUCTION

Left ventricular thrombus (LVT) increases the risk of ischemic stroke. However, it remains uncertain if the percutaneous coronary intervention (PCI) in the confirmed LVT setting further augments the stroke risk. Therefore, in this study, we evaluated the risk of stroke among patients with LVT undergoing CAG +/- PCI.

METHODS

This retrospective observational cohort study included all the patients encountered with LVT from 1st of April 2015, to 31st of March 2020. The study population was divided into two groups: Longobardo et al. (2018) [1] patients with LVT who underwent CAG +/- PCI; Solheim et al. (2010) [2] patients with LVT who did not undergo CAG +/- PCI. The primary outcome evaluated was stroke during the index admission, and the secondary outcomes included in-hospital mortality, all-cause mortality, and stroke at 12 months post-discharge. Logistic regression was used to determine the risk of stroke associated with PCI among patients with LVT, and a p-value<0.05 indicated statistical significance.

RESULTS

Of the 210 patients included, 119 underwent CAG +/- PCI, while 91 patients did not undergo CAG +/- PCI. Most of the patients were Asian (67%), male (96%), with a mean age of 56 years. Ischemic cardiomyopathy was the primary etiology of LVT in both groups (96% in the CAG +/- PCI group and 80% in non CAG +/- PCI group). During the index admission, stroke among patients with LVT did not differ between the CAG +/- PCI and non CAG +/- PCI groups (5% versus 3.3%; odds ratio (OR) 1.6, 95% confidence interval (CI) 0.34-6.4, p = 0.539; adjusted OR 0.9, 95% CI 0.09-10.6, p = 0.968). Similarly, in-hospital mortality, all-cause mortality, and stroke at 12 months did not differ between the study groups.

CONCLUSION

Performing CAG +/- PCI among patients with LVT was not associated with an increased risk of stroke during admission or within 12 months in comparison to patients who did not undergo CAG +/- PCI, which may reassure cardiologists to perform CAG +/- PCI among patients with LVT safely.

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.

Case of left ventricular thrombus managed with thrombectomy with left ventricular reconstruction in a patient who had coronavirus disease 2019 infection

BACKGROUND

Intracardiac thrombus is relatively rare in patients with coronavirus disease 2019 (COVID-19). However, if it occurs, thrombotic complications are likely to develop. In this case, we performed a successful thrombectomy on a patient who developed left ventricular thrombus after COVID-19 infection without complications.

CASE PRESENTATION

A 52-year-old man sought medical care due to fever, dyspnea, and abnormalities in the taste and smell that persisted for 2 weeks. The patient was diagnosed with COVID-19 and was treated with remdesivir, baricitinib, and heparin. Three weeks after hospitalization, electrocardiogram revealed angina pectoris, and cardiac catherization showed left anterior descending coronary artery stenosis. In addition, global hypokinesis and a thrombus at the left ventricular apex were observed on echocardiography. Left ventricular reconstruction concomitant with coronary artery bypass grafting was performed. A thrombus in the left ventricle was resected via left apical ventriculotomy, and the bovine pericardium was covered and sutured on the infarction site to exclude it. The patient was extubated a day after surgery and was transferred to another hospital for recuperation after 20 days. He did not present with complications.

CONCLUSIONS

Thrombotic events could be prevented via thrombectomy with left ventricular reconstruction using an intraventricular patch to exclude the residual thrombus.

Direct Oral Anticoagulants Versus Vitamin K Antagonists in the Treatment of Left Ventricular Thrombi

Left ventricular thrombi form due to the presence of Virchow's triad in patients with left ventricular systolic dysfunction. This complication increases the incidence of systemic embolization, hence anticoagulation is recommended to decrease this risk. Up to the present time, vitamin K antagonists are recommended by all societal guidelines for patients with left ventricular thrombi. Recently, several studies have investigated the role of different anticoagulants and yielded promising outcomes. This opinion article focuses on the evidence supporting vitamin K antagonists and direct oral anticoagulants in patients with left ventricular thrombi.

Safety and Effectiveness of Direct Oral Anticoagulants Versus Warfarin for Treating Left Ventricular Thrombus

BACKGROUND

Patients with left ventricular thrombus are at high risk for ischemic stroke and systemic embolization. The mainstay of treatment is anticoagulation, but it remains unclear if direct-acting oral anticoagulants (DOACs) are a safe and effective treatment strategy compared to warfarin. We conducted a population-based retrospective cohort study to evaluate the effectiveness and safety of DOACs compared to warfarin in an integrated health system in the United States.

METHODS

Consecutive patients with left ventricular thrombus on transthoracic echocardiogram from May 2010 to April 2020 were identified. Comparative effectiveness and safety of DOACs and warfarin were evaluated using multivariable Cox proportional hazard models and inverse probability of treatment weighting.

RESULTS

Among 433 patients with left ventricular thrombus, 134 (30.9%) were treated with DOACs and 299 (69.1%) were treated with warfarin. Patients were followed for a median of 3.4 years. For the primary effectiveness outcome of ischemic stroke, systemic embolism, and transient ischemic attack, no significant difference was observed between use of DOACs compared to warfarin (adjusted hazard ratio [HR] of 0.75, 95% confidence interval [CI] 0.48-1.18, p = 0.21). For the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed requiring hospitalization, DOAC usage was associated with a lower risk of bleeding (HR 0.58, 95% CI 0.39-0.87, p = 0.0008).

CONCLUSIONS

In this diverse population-based cohort of patients, DOAC treatment for left ventricular thrombus appears to be as safe and effective as warfarin treatment. These findings support the use of DOACs for patients with left ventricular thrombus.

Left Ventricular Thrombus Formation in a Structurally and Functionally Normal Heart: A Case Report and Literature Review

Left ventricular (LV) thrombosis usually occurs as a complication of acute anterior myocardial infarction (MI) and dilated cardiomyopathy. It also occurs in patients with a hypercoagulable state. However, in the setting of normal systolic function, LV thrombi are extremely rare. We present a case of a healthy woman who had LV thrombus despite normal LV systolic function that presented as an acute aortoiliac embolism.

Efficacy and safety of direct oral anticoagulants for treatment of left ventricular thrombus; a systematic review

INTRODUCTION

Left ventricular thrombus (LVT) is a well-recognised complication of ischaemic and non-ischaemic heart disease. The incidence of this complication has drastically reduced due to reperfusion therapies. Current guidelines recommend using warfarin for at least three months. But, direct-acting oral anticoagulants (DOACs) are increasingly used as an off-label alternative to vitamin K antagonists (VKA) to treat LVT. In this article, we will review the use of DOACs for the treatment of LVT.

METHODS AND RESULTS

We conducted a literature search for published case series, meta-analyses, and review articles in four electronic databases: PubMed, EMBASE, OVID, and Google Scholar from inception until 1 August 2020. Fifteen articles including meta-analyses, review articles and case series were included. A total of 292 patients with LVT from 7 articles are analysed. The majority (n = 110) were treated with rivaroxaban followed by apixaban (n = 86), and warfarin (60). 26 patients from 292 were not included in the analysis. Of the 206 patients on DOACs, 180 (87.3%) had resolution of LVT. 22 had persistent LVT. Six patients had reported bleeding. Three patients had gastrointestinal (GI) bleeding. One patient had pulmonary haemorrhage while one other had epistaxis requiring blood transfusion. Five of six patients who had bleeding were on either single or dual antiplatelet therapy in addition to DOAC. One patient had reported a cardioembolic stroke while on a DOAC. Median follow-up duration varied from one month to two years.

CONCLUSION

Based on our review, DOACs are likely to be at least as effective and safer as VKA for stroke prevention and thrombus resolution in patients with LVT.

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

The role of echocardiography in the embolic stroke of undetermined source

: Echocardiography plays an important role both in the diagnosis and the treatment/prevention of embolic stroke of undetermined source and should be performed as soon as possible for preventing ischemic stroke recurrencies, which occur more frequently during the first week after the first ischemic event. Early identification of the cause of a transient ischemic attack or stroke is indeed a primary goal for the neurologist in the Stroke Unit and requires specific diagnostic strategies. Echocardiography, together with other diagnostic tools such as carotid and transcranial ultrasounds, provides this information promptly. In particular, echocardiography might be able to detect the main sources of the embolic stroke, such as atrial fibrillation, ventricular akinesia, aortic atheroma plaques and/or cardiac shunts. The present review discusses the importance and the practical role of echocardiography as a crucial diagnostic tool for detecting the main source of emboli in the setting of the acute stroke.

Large left ventricular thrombus surgically resected in a patient with normal ejection: A case report

INTRODUCTION

A left ventricular thrombus is very rare in a patient with normal systolic function. We are reporting a case of left ventricular thrombus in a patient with an abnormal presentation and normal ejection fraction.

PRESENTATION OF CASE

A 57-year-old female patient presented with severe epigastric and central abdominal pain associated with nausea, vomiting, constipation, and a decrease in appetite. Post-contrast abdominal computerized tomography (CT) scan revealed multiple splenic infarcts. On echocardiographic study, a huge hyperechogenic, mobile mass was seen attached to the septo-apical wall of the left ventricle measuring 20 mm × 40 mm. Magnetic resonance imaging (MRI) also showed transmural late gadolinium enhancement in the apex which is suggestive of small myocardial infarction in the distal left anterior descending territory. Coronary angiogram showed non-occluded coronaries. The patient was treated surgically due to the urgency of the situation and the high risk of embolization.

DISCUSSION

Our patient was on both progesterone and high dose tofacitinib. It is hypothesised that patient most likely experienced asymptomatic myocardial injury with non-occluded coronaries (MINOCA) weeks prior to the presentation. Involvement of distal left anterior descending artery caused apical akinesia resulting in blood stasis. Accompanying subendocardial injury and hypercoagulable state, due to being on progesterone and tofacitinib, led to the formation of the left ventricular thrombus.

CONCLUSION

Due to the serious outcomes associated with an untreated left ventricular thrombus, it is necessary to carefully assess all patients suffering from systemic embolism with echocardiogram. Assessing the left ventricular mass with MRI was crucial to understanding the nature of the mass. Size, mobility, and protruding nature where characteristics that warranted urgent surgical intervention due to the high risk of embolization. Finally, it is important to note that tofacitinib might be a new suspect for left ventricular clots.

Patients with Left Ventricular Thrombus Despite Normal Systolic Function

The formation of a thrombus in the left ventricle (LV) in patients with normal systolic function is very rare. We report a case and identified 31 other adult patients who had an LV thrombus with normal LV systolic function. The median (IQR) age of these patients was 43 [37,59] years with a slight male predominance (59%). The vast majority of patients presented with embolic complications (28; 88%) with 3 of the other patients presenting with a febrile illness. Most of the cases occurred in the setting of an identifiable medical condition that carries an increased risk of thrombosis including inflammatory diseases, malignancies or hypereosinophilia. Treatment generally included anticoagulation with or without surgical removal or systemic thrombolysis. Recurrence of LV thrombus and/or embolic events have been reported in patients with LV thrombus and normal LV systolic function suggesting that long term anticoagulation may be needed.

Warfarin versus direct oral anticoagulants for treating left ventricular thrombus: a systematic review and meta-analysis

BACKGROUND

Left ventricular thrombus (LVT) is not uncommon and pose a risk of systemic embolism, which can be mitigated by adequate anticoagulation. Direct oral anticoagulants (DOACs) are increasingly being used as alternatives to warfarin for anticoagulation, but their efficacy and safety profile has been debated. We aim to compare the therapeutic efficacy and safety of DOACs versus warfarin for the treatment of LVT.

METHODOLOGY

We systematically searched PubMed/Medline, Google Scholar, Cochrane library, and LILCAS databases from inception to 14th August 2020 to identify relevant studies comparing warfarin and DOACs for LVT treatment and used the pooled data extracted from retrieved studies to perform a meta-analysis.

RESULTS

We report pooled data on 1955 patients from 8 studies, with a mean age of 61 years and 59.7 years in warfarin and DOACs group, respectively. The pooled odds ratio for thrombus resolution was 1.11 (95% CI 0.51-2.39) on comparing warfarin to DOAC, but it did not reach a statistical significance (p = 0.76). The pooled risk ratio (RR) of stroke or systemic embolization and bleeding in patients treated with warfarin vs DOACs was 1.04 (95% CI 0.64-1.68; p = 0.85), and 1.15 (95% CI 0.62-2.13; p = 0.57), respectively; with an overall RR of 1.09 (95% CI 0.70-1.70; p = 0.48) for mortality.

CONCLUSIONS

DOACs appears to be non-inferior or at least as effective as warfarin in the treatment of left ventricular thrombus without any statistical difference in stroke or bleeding complications.

Left Ventricular Thrombus Formation in the Setting of Normal Systolic Function

We describe the case of a 42-year-old female with recurrent left ventricular (LV) thrombus and multiple embolic events despite having normal LV systolic function. The clinical presentation, associated conditions, diagnostic evaluation and treatment of patients with LV thrombus in the setting of normal LV systolic function are discussed. (Level of Difficulty: Beginner.)

Relationship between apical thrombus formation and blood viscosity in acute anterior myocardial infarction patients

Aim: This study sought to investigate the predictive value of whole blood viscosity (WBV) to identify high-risk patients who will develop an apical thrombus during the acute phase of anterior transmural infarction. Materials & methods: Consecutive 1726 patients with first acute anterior myocardial infarction were evaluated. WBV was calculated according to the Simone’s formula. Results: Patients with an apical thrombus had prolonged pain to balloon time, higher rate of post-PCI thrombolysis in myocardial infarction flow ≤1 and significantly higher mean WBV values at both shear rates than those without an apical thrombus. Conclusion: WBV values at both shear rates were found to be significant and independent predictors for early LV apical thrombus formation complicating a first-ever anterior wall myocardial infarction.

Role of Imaging for Suspected Cardiac Thrombus

PURPOSE OF REVIEW

Cardiac thrombus formation is a frequent complication of a variety of prevalent diseases. Embolism of cardiac thrombus has the potential to result in significant morbidity and mortality from cerebrovascular and peripheral vascular events.

RECENT FINDINGS

Echocardiography is the most commonly used imaging modality for diagnosing intracardiac thrombus. However, technological advances in computed tomography and magnetic resonance imaging have allowed newer noninvasive modalities to evolve into robust tools for the clinical evaluation of patients suspected of disease. Complimentary use of these imaging techniques is crucial in the diagnosis of cardiac thrombus and initiation of anticoagulation therapy.

Incidence and predictors of left ventricular thrombus formation following acute ST-segment elevation myocardial infarction: A serial cardiac MRI study

AIMS

Left ventricular (LV) thrombus is a complication of acute ST-segment elevation myocardial infarction (STEMI). We determined the incidence and predictors of LV thrombus formation using serial cardiac magnetic resonance (CMR) and two-dimensional echocardiography studies.

METHODS AND RESULTS

Two hundred and ten patients underwent CMR (median 4 days [IQR 3-7]) and transthoracic echocardiography (median 4 days [IQR 3-7]) early after STEMI presentation with serial follow-up CMR (median 55 days [IQR 46-64]) and echocardiography studies (median 54 days [IQR 45-64]) performed subsequently. The incidence of LV thrombus was 12.3% (26/210) by CMR and 6.2% (13/210) by two-dimensional echocardiography. Echocardiography had 50% sensitivity and 100% specificity for LV thrombus detection compared to CMR. LV thrombus was found in 23.6% of patients with anterior STEMI (22/93). Ischaemic stroke occurred in 1.4% of patients (3/210). Patients with LV thrombus had lower baseline LV ejection fraction (LVEF) (34.9% vs 47.4%, p < 0.001). Microvascular obstruction was more common in patients with LV thrombus (77% vs 39%, p < 0.001). Patients with LV thrombus had increased LV dimensions with larger LV end-diastolic (19 ml [IQR 9-44] vs 6 ml [IQR -4-18], p < 0.001) and end-systolic volumes (10 ml [IQR 0-22] vs -4 ml [IQR -12-4], p < 0.001).

CONCLUSION

CMR increases the detection of LV thrombi which standard echocardiography may underestimate. Serial studies post-STEMI may improve detection of LV thrombus, which is more prevalent in patients with anterior infarction, moderate LV dysfunction and adverse LV remodelling. This subgroup of patients may represent a high-risk group for targeted serial screening with CMR.

Shape and Mobility of a Left Ventricular Thrombus Are Predictors of Thrombus Resolution

BACKGROUND AND OBJECTIVES

Left ventricular (LV) apical thrombi are usually present with LV dilatation, and oral anticoagulants reduce embolic risk in these patients. However, echocardiographic data regarding thrombus resolution remain limited. We studied its echocardiographic features that were associated with early resolution (within 1 month).

METHODS

We performed a retrospective observational study by reviewing baseline and follow-up echocardiographic images and medical records in patients with LV apical thrombi.

RESULTS

Between January 2005 and December 2017, 77 patients (59 males, mean 61±12 years old) were enrolled. Patients were classified into 2 groups based on duration of thrombus resolution: group 1 showing resolution within 1 month (n=23) and group 2 with persistence after 1 month (n=54). Thrombus size was significantly smaller in group 1 (10.7±4.2 vs. 12.1±5.5 mm, p=0.046). Grade 1 mobility (partially mobile; odds ratio [OR], 7.800; p=0.012) and grade 2 mobility (highly mobile; OR, 14.625; p=0.002) were significantly associated with the early resolution. Round thrombi were associated with early resolution than mural form (OR, 3.187; p=0.026). Multivariate analysis showed that the mobility was the most important parameter, and a highly mobile (grade 2 mobility) LV apical thrombi showed earlier resolution (OR, 12.525; p=0.013). During the follow-up over 62±44 months, 25 patients (32.5%) had ≥1 adverse clinical events. The late resolution of thrombi was associated with poor long-term clinical outcomes (hazard ratio, 5.727; p=0.020).

CONCLUSIONS

Mobility of LV apical thrombi was the most important parameter associated with early thrombus resolution. Late resolution of LV apical thrombi was associated with poor long-term clinical outcomes.

Role of Echocardiography in Assessment of Cardioembolic Sources: a Strong Diagnostic Resource in Patients with Ischemic Stroke

PURPOSE OF REVIEW

This review will discuss the most frequent sources of cardiac embolism and the role of echocardiography in these different clinical settings, and, in addition, provide suggestions about the choice between transthoracic (TTE) and transesophageal echocardiography (TEE).

RECENT FINDINGS

Stroke is the third leading cause of death in industrial countries, and 15-40% of all ischemic strokes are due to cardioembolism. TTE and TEE are cornerstones in the detection of cardioembolic sources and provide fundamental information about the embolic risk and most suitable treatment of these patients, improving long-term outcomes. Echocardiography is a widely available, inexpensive, and safe diagnostic tool that is almost free from contraindication, and these elements allow the common use of this technique in almost all the patients with ischemic stroke. The most common cardioembolic sources include left atrial appendage thrombosis during atrial fibrillation; vegetations in infective endocarditis; cardiac masses including left ventricular thrombosis, cardiac tumors, etc.; atherosclerotic plaques; and passageways within the heart serving as conduits for paradoxical embolization, e.g., patent foramen ovale.

Incidence of Left Ventricular Thrombus in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated with Percutaneous Coronary Intervention

Previous studies using 2-dimensional non-contrast echocardiography have reported a post-ST segment elevation myocardial infarction (STEMI) left ventricular (LV) thrombus incidence of 3% to 24%. However, these studies were not performed with ultrasound contrast agents (UCAs), which improve accuracy in the diagnosis of LV thrombus. We aimed to determine the early incidence and clinical correlates of LV thrombus in a large consecutive cohort of patients with STEMI. This study included consecutive patients admitted to Saint Luke's Mid America Heart Institute with STEMI who also underwent early percutaneous coronary intervention (PCI) and an echocardiogram. A total of 1,698 patients (1,205 men, mean age 61 ± 13 years) comprised the study group. Echocardiography was performed on hospital day 2, and a UCA was used in 1,292 patients (76%). LV thrombus was identified in 28 (1.6%) patients. A multivariable logistic regression model showed that left anterior descending intervention was independently associated with LV thrombus (odds ratio = 7.58, 95% confidence interval [CI] 2.20 to 26.19, p = 0.001), thrombolysis in myocardial infarction III flow was marginally associated with less LV thrombus (odds ratio = 0.41, 95% CI 0.16 to 1.04, p = 0.060), and higher LVEF was associated with less LV thrombus (odds ratio = 0.96, 95% CI 0.91 to 0.97, p <0.001). In conclusion, LV thrombus was identified in only 1.6% of patients in a large STEMI cohort, significantly lower than previous studies. A UCA was used in most echocardiograms, and it improves accuracy in the detection and exclusion of LV thrombus.

A Large Left Ventricular Cystic Thrombus: Unusual Presentation of a Common Entity

•LV thrombi after AMI are a feared complication and are not uncommon. •LV thrombi can present unusually as cystic-like masses, warranting careful management. •Early identification and management of LV thrombi can prevent devastating sequelae.

Impaired left ventricular diastolic function is related to the formation of left ventricular apical thrombus in patients with acute anterior myocardial infarction

Left ventricular (LV) apical thrombus is a clinically important complication which can cause systemic embolization in patients with anterior acute myocardial infarction (AMI). Systolic dysfunction has been a risk factor for developing LV apical thrombus in AMI patients. However, the role of diastolic dysfunction in the development of LV apical thrombus in these patients is still unknown. We performed this study to evaluate whether diastolic dysfunction can influence the development of LV apical thrombus in anterior AMI patients. We retrospectively analyzed all consecutive anterior AMI patients with available echocardiographic images within 1 month from January 2005 to April 2016. After gathering clinical characteristics from their medical records, systolic and diastolic functions were analyzed from digitally stored echocardiographic images. We included a total of 1045 patients (748 males, mean age 64 ± 12 years) with anterior AMI, and 494 (47%) were diagnosed as STEMI. The incidence of LV apical thrombus was 3.3% (34/1045). The LV apical thrombus group had larger LV diastolic dimension, larger LV diastolic and systolic volumes, and lower LVEF than the no LV thrombus group. The LV apical thrombus group showed higher mitral E velocity over mitral annular E' velocity ratio, an indicator of LV end-diastolic pressure (P < 0.001). In the LV apical thrombus group, the incidence of grade 2 diastolic dysfunction (32 vs 12%, P = 0.001) and grade 3 diastolic dysfunction (26 vs 2%, P < 0.001) were significantly higher than in the no LV apical thrombus group. The presence of more than grade 2 diastolic dysfunction, LVEF and presence of LV apical aneurysm were statistically significant factors associated with LV apical thrombus after the multivariate analysis. In conclusion, along with LV systolic dysfunction and LV apical aneurysm, LV diastolic dysfunction was also related with the presence of LV apical thrombus in patients with anterior AMI.

Outcomes and Prognostic Impact of Prophylactic Oral Anticoagulation in Anterior ST-Segment Elevation Myocardial Infarction Patients With Left Ventricular Dysfunction

Background

The contemporary role of prophylactic anticoagulation following extensive anterior wall ST‐segment myocardial infarction (STEMI) is unclear.

Methods and Results

We evaluated anterior STEMI patients with left ventricle dysfunction (left ventricular ejection fraction ≤40%) (“high risk”), categorized by prophylactic warfarin use, within a regional STEMI. Patients with pre‐existing atrial fibrillation were excluded. The primary outcome was an adjusted (for Global Registry of Acute Coronary Events risk score) 1‐year composite of recurrent ischemia, stroke/transient ischemic attack/systemic embolism, or all‐cause death. Of the 2032 STEMI admissions, 436 (21.5%) were high risk. After excluding 19 (4.4%) patients with definite left ventricle thrombus and 21 (4.8%) in‐hospital deaths (2 had left ventricle thrombus), prophylactic warfarin was utilized in 236/398 (59.3%) high‐risk survivors. Prescriptions were comparable across sex, but recipients were on average younger (58.5 years versus 64.0 years, P<0.001) and lower risk (Global Registry of Acute Coronary Events risk: 163 versus 181, P<0.001). No association on the adjusted ischemic composite (23.3% versus 25.3%, odds ratio 0.96, 95% CI 0.60–1.55) or thromboembolic events (2.1% versus 1.2%, odds ratio 1.99, 95% CI 0.38–10.51) was observed, but reduced 1‐year all‐cause mortality was noted (2.5% versus 8.6%, odds ratio 0.30, 95% CI 0.11–0.81); numerically higher major bleeding was observed at 1 year (2.5% versus 1.2%, odds ratio 2.17, 95% CI 0.43–10.96).

Conclusions

A high utilization of prophylactic warfarin occurs in anterior STEMI patients with left ventricle dysfunction, yet appears to provide no additional benefit on the ischemic composite. The association with lower all‐cause mortality, but higher bleeding, calls for an improved understanding of its role in high‐risk STEMI.

Large In-transient Left Ventricular Thrombus due to Anabolic Steroid-induced Cardiomyopathy

The presence of small or moderate size thrombosis is not uncommon in left ventricle (LV) as results of basic co-moribund disease, but huge LV thrombosis that protrudes to aortic valve in the LV outflow tract (LVOT) tract is an exceptionally rare phenomenon. We report a 34-year-old bodybuilder athlete with cardiomyopathy and massive LV thrombosis. The thrombosis extended to LVOT and protruded through the aortic valve in systole and posed a high risk of systemic emboli. The patient underwent open heart surgery, and the clot was removed. The operation was complicated by low cardiac output syndrome that managed by intra-aortic balloon pump and high dose of inotropic drugs and hemodialysis. The patient died on the 15^th day after surgery with multiorgan failures.

Clinical predictors and outcomes of patients with left ventricular thrombus following ST-segment elevation myocardial infarction

We aimed to characterize the independent predictors of LVT following STEMI and the association with outcomes. The clinical predictors of left ventricular thrombus (LVT) formation after ST-segment elevation myocardial infarction (STEMI) are not well-defined in the contemporary era. We performed a retrospective analysis of STEMI patients at Duke from 2000 to 2011 who had a transthoracic echocardiogram within 90 days post-STEMI and compared patients with and without LVT (LVT+ vs. LVT-). Univariate Cox proportional hazards regression models of baseline characteristics were examined and significant variables were used in a multivariable model to assess adjusted relationships with LVT. A multivariable Cox PH survival model with covariate adjustments was used for assessment of LVT and long-term mortality. Of all eligible patients, 1734 patients met inclusion criteria and 4.3 % (N = 74) had a LVT. LVT+ patients tended to have a history of heart failure (HF) and higher initial troponin compared to LVT- patients. After adjustment, higher heart rate, non-white race, HF severity, and presence of left anterior descending artery (LAD) disease were independent predictors of LVT. There was a trend toward an association between LVT and increased all-cause mortality (HR 1.36; 95 % CI 0.84-2.21, P = 0.22), however this was not statistically significant. LVT was seen in over 4 % of this contemporary post-STEMI population. Several baseline characteristics were independently associated with LVT: Heart rate, HF severity, LAD disease, and non-white race. Prospective studies are warranted to determine whether anticoagulation in patients at increased risk for LVT improves outcomes.

Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism

Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

Use of Heparin in Acute Ischemic Stroke: Is There Still a Role?

Heparin has long been a contested therapy in acute ischemic stroke (AIS). In current practice, heparin is considered on a case-by-case basis, but there is no consensus as to the appropriate timing of anticoagulation or for which ischemic stroke subtypes heparin may be beneficial. To provide better clarity on this issue, we review current research focusing on the use of heparin in AIS in each stroke subtype and subsequently make recommendations to provide readers with a systematic approach to managing complex stroke patients for which acute anticoagulation may be valuable. We conclude that there are certain subpopulations of ischemic stroke patients that may derive benefit from heparin when given acutely, including patients with symptomatic large artery stenosis >70 %, non-occlusive intraluminal thrombus, and in patients with high-risk cardiac conditions including left ventricular thrombus, left ventricular assist devices, and mechanical heart valves.

Secondary stroke prevention: challenges and solutions

Stroke is the leading cause of disability in the USA and a major cause of mortality worldwide. One out of four strokes is recurrent. Secondary stroke prevention starts with deciphering the most likely stroke mechanism. In general, one of the main goals in stroke reduction is to control vascular risk factors such as hypertension, diabetes, dyslipidemia, and smoking cessation. Changes in lifestyle like a healthy diet and aerobic exercise are also recommended strategies. In the case of cardioembolism due to atrial fibrillation, mechanical valves, or cardiac thrombus, anticoagulation is the mainstay of therapy. The role of anticoagulation is less evident in the case of bioprosthetic valves, patent foramen ovale, and dilated cardiomyopathy with low ejection fraction. Strokes due to larger artery atherosclerosis account for approximately a third of all strokes. In the case of symptomatic extracranial carotid stenosis, surgical intervention as close as possible in time to the index event seems highly beneficial. In the case of intracranial large artery atherosclerosis, the best medical therapy consists of antiplatelets, high-dose statins, aggressive controls of vascular risk factors, and lifestyle modifications, with no role for intracranial arterial stenting or angioplasty. For patients with small artery occlusion (ie, lacunar stroke), the therapy is similar to that used in patients with intracranial large artery atherosclerosis. Despite the constant new evidence on how to best treat patients who have suffered a stroke, the risk of stroke recurrence remains unacceptably high, thus evidencing the need for novel therapies.

Left ventricular thrombus development during ventricular fibrillation and resolution during resuscitation in a swine model of sudden cardiac arrest

BACKGROUND

Intracardiac thrombus is a well-known complication of low-flow cardiac states including acute myocardial infarction and atrial fibrillation. Little is known, however, about the formation of intracardiac (left ventricular [LV]) thrombus during the extreme low-flow state of cardiac arrest.

OBJECTIVE

Using a swine model of sudden cardiac arrest, we examined the sonographic development of LV thrombus over time after induction of ventricular fibrillation (VF) and resolution of thrombus with cardiopulmonary resuscitation (CPR).

METHODS

This observational study was IACUC approved. Forty-five Yorkshire swine were sedated, intubated, and instrumented under general anesthesia before VF was electrically induced. Sonographic data was collected immediately after VF induction and at 2-min intervals thereafter. Following 12min of untreated VF, resuscitation was initiated with closed chest compressions using an oxygen-powered mechanical resuscitation device. Observations were continued during attempted resuscitation. At the end of the experiment, the animals were euthanized while still at a surgical depth of anesthesia. The data was analyzed descriptively.

RESULTS

Sonographic evidence of LV thrombus was observed in 43/45 animals (95.6% [95%CI: 85.2%, 98.8%]). Thrombus was detected within 6min in 39/45 (86.7% [95%CI: 73.8%, 93.8%]) animals that developed thrombus. Thrombus resolved within 2min after initiation of chest compressions in 31/43 (72.1% [95%CI: 57.3%, 83.3%]) animals.

CONCLUSION

Similar to other low-flow cardiac states, LV thrombus develops early in the natural history of VF arrest and resolves quickly once forward flow is re-established by chest compressions. Institutional protocol number: 154600-8.

Hemorrhagic cardioembolic stroke secondary to a left ventricular thrombus: a therapeutic dilemma

Cardiogenic embolism is a major cause of stroke and often leads to significant morbidity and mortality. Despite the recent advances in our understanding of the pathophysiology of stroke and its risk factors, diagnosis and therapy; some case scenarios still present a real challenge for the treating physicians. We report a case of a 50 year old male patient presenting with multi-territory cerebral infarctions due to a left ventricular mobile thrombus complicated with hemorrhagic transformation at the time of presentation. Gradual introduction of anticoagulation coupled with a multidisciplinary team approach advocating careful daily clinical assessment of the patient and regular echocardiographic and neuroimaging studies have resulted in a better management and achievement of therapeutic goals.

Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents

Left ventricular (LV) thrombus is one of the risk factors for systemic thromboembolism. The aims of this study were to compare the long-term clinical outcomes of LV thrombus using current therapeutics, anticoagulation, operative treatment, and antiplatelet agents and to identify independent predictors of systemic thromboembolism.

METHODS

We screened 86,374 patients for intracardiac thrombus in the electronic medical records and imaging databases. Records of 62 patients with LV thrombus, diagnosed between May 2003 to November 2011, were comprehensively reviewed regarding baseline characteristics, imaging data and thrombus outcomes, thromboembolic events and treatment complications by treatment group.

RESULTS

The majority (80.6%) had ischemic etiology. Systemic thromboembolism developed in 18 patients; 8 (45%) were post-treatment thromboembolisms while 10 events occurred before treatment began. No post-treatment thromboembolism occurred in the operative treatment group; in contrast, 7 post-treatment thromboembolisms occurred in anticoagulation group (17%) (Log rank p= 0.175). Independent predictors of post-treatment thromboembolism were dilated cardiomyopathy (HR 61.30, p= 0.001), previous cerebrovascular events (HR 7.06, p= 0.042), female gender (HR 7.11, p= 0.031), and echocardiographic left ventricular end-diastolic diameter (HR 1.15, p= 0.047).

CONCLUSIONS

In this study, the rate of post-treatment thromboembolism was not significantly different among the treatment groups; however, operative treatment tended towards less post-treatment thromboembolism than other treatment groups.

Left ventricular thrombus in patients with acute myocardial infarction:Case report and Caribbean focused update

Despite the well documented benefit of echocardiography in acute coronary syndromes, its wide-scale use in the Caribbean is limited by access, health literacy and affordability. Because of the limited use of echocardiography in the region, routine complications of acute myocardial infarction (AMI) are not fully appreciated and may go unrecognized, further contributing to increased cardiovascular morbidity and mortality. It is therefore necessary to bring focus to this common clinical condition and highlight the clinical utility of echocardiography in facilitating timely and accurate diagnosis. We report here a case of large left ventricular (LV) thrombus in a patient with AMI. Coronary angiography showed completely occluded left anterior descending artery (LAD) with angiographically normal remaining vessels. Immediate anticoagulation was commenced with heparin and overlapped with warfarin. No Primary Angioplasty (PA) was done based on the evidence from occluded artery trial. LV thrombus was completely resolved on echocardiography at three months. No evidence of thrombo-embolism was found during the resolution of LV thrombus.

The role of echocardiography in the management of the sources of embolism

The echocardiographic diagnosis of cardiac thrombi, vegetations and tumors as well as the identification of predisposing conditions such as patent foramen ovale, aortic atherosclerosis and other minor causes (e.g., mitral valve prolapse, mitral and aortic valve calcification) have crucial clinical relevance, affecting the choice of surgery and/or of pharmaceutical therapy in the setting of patients presenting embolism. The echocardiographic assessment helps not only for the retrospective diagnosis of sources of embolism but also for the prevention of events in asymptomatic patients. Echocardiography can also distinguish normal variants and artifacts from cardiac masses and tumors. Echocardiographic characterization/typology of cardiac sources of embolism is currently below par when compared with cardiac MRI, the current gold standard. Nevertheless, echocardiography remains the 'first-line' imaging tool, because of its low cost and the possibility to add easily available, functional and structural information at the patient's bedside.