Predictors of left ventricular thrombus formation and disappearance after anterior wall myocardial infarction

Stasis imaging predicts the risk of cardioembolic events related to acute myocardial infarction: the ISBITAMI study

INTRODUCTION AND OBJECTIVES

In the setting of ST-segment elevation myocardial infarction (STEMI), imaging-based biomarkers could be useful for guiding oral anticoagulation to prevent cardioembolism. Our objective was to test the efficacy of intraventricular blood stasis imaging for predicting a composite primary endpoint of cardioembolic risk during the first 6 months after STEMI.

METHODS

We designed a prospective clinical study, Imaging Silent Brain Infarct in Acute Myocardial Infarction (ISBITAMI), including patients with a first STEMI, an ejection fraction ≤ 45% and without atrial fibrillation to assess the performance of stasis metrics to predict cardioembolism. Patients underwent ultrasound-based stasis imaging at enrollment followed by heart and brain magnetic resonance at 1-week and 6-month visits. From the stasis maps, we calculated the average residence time, RT, of blood inside the left ventricle and assessed its performance to predict the primary endpoint. The longitudinal strain of the 4 apical segments was quantified by speckle tracking.

RESULTS

A total of 66 patients were assigned to the primary endpoint. Of them, 17 patients had 1 or more events: 3 strokes, 5 silent brain infarctions, and 13 mural thromboses. No systemic embolisms were observed. RT (OR, 3.73; 95%CI, 1.75-7.9; P<.001) and apical strain (OR, 1.47; 95%CI, 1.13-1.92; P=.004) showed complementary prognostic value. The bivariate model showed a c-index=0.86 (95%CI, 0.73-0.95), a negative predictive value of 1.00 (95%CI, 0.94-1.00), and positive predictive value of 0.45 (95%CI, 0.37-0.77). The results were confirmed in a multiple imputation sensitivity analysis. Conventional ultrasound-based metrics were of limited predictive value.

CONCLUSIONS

In patients with STEMI and left ventricular systolic dysfunction in sinus rhythm, the risk of cardioembolism may be assessed by echocardiography by combining stasis and strain imaging. Registered at ClinicalTrials.gov (NCT02917213).

Incidence and Predictors of Left Ventricular Thrombus Formation After Acute Myocardial Infarction With ST-Segment Elevation

Background and objective Our prospective study aimed to evaluate the frequency and risk factors of left ventricular thrombus (LVT) occurring after acute ST-segment elevation myocardial infarction (STEMI) in the era of primary percutaneous coronary intervention (PCI). Methods Our study included 131 patients diagnosed with acute STEMI who were followed up and treated. The presence of the thrombus was determined by transthoracic echocardiography (TTE). Study patients were evaluated as cases of thrombus (+) and thrombus (-). The relationship of electrocardiographic measurements such as the number of leads with pathological Q waves, ST segment deviation score, QT dispersion, and echocardiographic measurements such as ejection fraction (EF), end-systolic and end-diastolic volumes, and wall motion score index (WMSI) with LVT was investigated. LVT risk factors were identified. Results The median age of the study patients was 59.7 ± 11.7 years, and 84.7% were male. The incidence of LVT was 17.6% (23 patients). While the anterior STEMI rate was 86.9% in the thrombus (+) group, it was 50.9% in the thrombus (-) group (p<0.001). While WMSI was 2.1 ± 0.44 in the thrombus (+) group, it was calculated as 1.40 ± 0.31 in the thrombus (-) group (p<0.001). In the thrombus (+) group, EF was found to be lower, end-systolic and end-diastolic volumes were higher, and the rate of moderate and severe mitral regurgitation and the rate of aneurysmatic segment detection were higher. LVT had a moderate correlation with WMSI (r: 0.613; p<0.001), the presence of an aneurysmatic segment (r: 0.549; p<0.001), and EF (r: -0.514; p<0.001). Presentation with anterior STEMI (odds ratio [OR]: 4.266; p<0.001), WMSI (OR: 7.971; p=0.012), the number of leads with pathological Q waves detected at discharge (OR: 3.651; p=0.009), the presence of an aneurysmatic segment (OR: 2.089, p=0.009), and EF (OR: 1.129, p=0.006) were identified as independent risk factors of the presence of LVT. The area under the curve for WMSI was found to be 0.910 (95% CI: 0.852-0.968). A WMSI cut-off of 1.56 identified LVT with 91% sensitivity and 70% specificity (Youden index: 0.617). Conclusion In the primary PCI era, LVT incidence after acute STEMI is still significant. Anterior STEMI, the number of leads with pathological Q waves detected at discharge, WMSI, aneurysm formation, and low EF are independent risk factors for LVT. Among these risk factors, the variable with the highest diagnostic power is WMSI.

Effect of Duration of Anticoagulation in the Incidence of Stroke in Patients With Left-Ventricular Thrombus

The optimal duration of anticoagulation in patients with left-ventricular thrombus (LVT) is unclear. In the present study, we aimed to analyze the effect of treatment duration (≤12 months [short-term anticoagulation, (STA)] versus >12 months [long-term anticoagulation, (LTA)]) in the incidence of stroke and other secondary outcomes (acute myocardial infarction, bleeding, and mortality). Multivariate Cox regression was used to determine the association between treatment duration and stroke, adjusted for baseline embolic risk. A total of 98 cases of LVT (age 64.3 ± 12.8 years, female 18 [18%]) were identified. Sixty-one patients (62%) received LTA. Patients receiving LTA were older than those receiving STA (66.5 ± 11.6 vs 60.7 ± 13.9 years, p = 0.029), more often had atrial fibrillation (31% vs 0%, p <0.001), and had a higher CHA₂DS₂-VASc score (4.3 ± 1.6 vs 3.6 ± 1.6, p = 0.046). Stroke occurred in 2 and 10 patients (3% vs 27%, p <0.001), acute myocardial infarction in 2 and 3 patients (3% vs 8%, p = 0.292), bleeding in 4 and 3 patients (7% vs 8%, p = 0.773), and mortality in 12 and 7 patients (20% vs 19%, p = 0.927) in the LTA and STA groups, respectively. In multivariate analysis, after adjusting for embolic risk, LTA was associated with decreased risk of stroke at 5 years (adjusted hazard ratio 0.16; 95% confidence interval 0.03 to 0.72, p = 0.017). In conclusion, our data suggest that prolonged anticoagulation in patients with LVT may be associated with significantly lower risk of stroke.

Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis

BACKGROUND

Current guidelines recommend vitamin K antagonists (VKAs) to reduce the risk of systemic thromboembolic (STE) events in patients with left ventricular (LV) thrombus. Direct oral anticoagulants (DOACs) are an emerging alternative to VKAs; however, data supporting DOAC use in LV thrombus are still lacking. We conducted this systematic review and meta-analysis to compare the efficacy and safety between DOACs and VKAs in this population.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library databases from inception to October 2020 to identify studies that compared clinical outcomes of interest, including stroke or any STE, LV thrombus resolution, and bleeding, between patients who used DOACs and VKAs for LV thrombus. Data from each study were combined using the random-effects model.

RESULTS

Eight cohort studies with a total of 1771 patients (426 in DOAC group, 1345 in VKA group) were included. There were no statistically significant differences between VKA group and DOAC group on rates of STE events (pooled RR = 1.12, 95% confidence interval [CI]: 0.91-1.39, p = .286), LV thrombus resolution (pooled RR = 1.09, 95% CI: 0.94-1.27, p = .242), or bleeding events (pooled RR = 0.94, 95% CI: 0.59-1.51, p = .808).

CONCLUSIONS

Our meta-analysis found no significant differences in rates of STE events, LV thrombus resolution, or bleeding events between the use of DOACs and VKAs in LV thrombus. Further randomised controlled trials are needed to confirm our findingsHighlightsThere is limited evidence comparing the use of direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in left ventricular (LV) thrombus.Our systematic review and meta-analysis showed that DOACs are not inferior to VKAs in the incidence of systemic thromboembolism (STE), the rate of LV thrombus resolution, and the risk of bleeding.Current evidence is based on observational studies only. Further randomised controlled trials are needed to confirm the findings.

Direct Oral Anticoagulants Versus Warfarin in the Treatment of Left Ventricular Thrombus

BACKGROUND

Use of direct oral anticoagulants (DOACs) for the treatment of left ventricular (LV) thrombus has gained considerable interest.

OBJECTIVE

We aimed to evaluate if DOACs are effective in the treatment of LV thrombus compared with warfarin.

METHODS

We evaluated the medical records of patients diagnosed with a new LV thrombus at a tertiary medical center. The primary outcome was the composite of thrombus persistence, stroke, or systemic embolism. We adjusted for potential confounders using multiple logistic regression. The safety outcome was the composite of hemorrhagic stroke or bleeding requiring blood transfusion.

RESULTS

A total of 129 patients were treated with warfarin and 22, with a DOAC. In unadjusted analysis, 54.3% of patients treated with warfarin met criteria for the efficacy outcome as compared with 40.9% of patients treated with a DOAC (P = 0.25). In adjusted analysis, no difference between groups was observed (odds ratio = 0.39; 95% CI = 0.14-1.06; P = 0.07 for DOAC vs warfarin). In all, 3.9% of patients treated with warfarin met safety criteria as compared with 4.5% of patients treated with a DOAC. A total of 8 patients in the warfarin group had a stroke or systemic embolism as compared with 0 patients in the DOAC group (P = 0.37).

CONCLUSION AND RELEVANCE

Our data suggest that DOACs may be reasonable alternatives for treatment of LV thrombus. When added to the totality of available studies, this study demonstrates that the effectiveness of DOACs in LV thrombus remains uncertain. Randomized clinical trials are needed.

The prevalence, predictors, and outcomes of spontaneous echocardiographic contrast or left ventricular thrombus in patients with HFrEF

Aims

This study aimed to determine prevalence, predictors, and association with ischaemic stroke risk of spontaneous echocardiographic contrast (SEC) or left ventricular thrombus (LVT) in patients with heart failure with reduced ejection fraction (HFrEF).

Methods and results

Clinical, echocardiographic, and follow‐up data from January 2009 through February 2019 were retrospectively extracted from electronic medical records of patients with heart failure with left ventricular ejection fraction < 40% by echocardiography on admission, with follow‐up to February 2020. Of 9485 consecutive patients with HFrEF, 123 (1.3%) presented LVT and 331 (3.5%) presented SEC. Patients with vs. those without SEC/LVT had larger left ventricular end‐diastolic volume (199.5 ± 77.7 vs. 165.8 ± 61.3 mL, P < 0.001), lower left ventricular ejection fractions (29.5 ± 7.0% vs. 33.7 ± 5.5%, P < 0.001), and more often ischaemic cardiomyopathy, apical aneurysm, chronic kidney diseases, and smoking habit. In Cox regression analysis, SEC and LVT were independent predictors for ischaemic stroke occurrence [hazard ratio (HR) = 2.40, 95% confidence interval (CI): 1.74–3.31; HR = 4.52, 95% CI: 2.77–7.40, both P < 0.001]. In patients with those without SEC or LVT, stroke risk was higher among those not on anticoagulants (HR = 2.55, 95% CI: 1.85–3.53; HR = 4.71, 95% CI: 2.84–7.81, both P < 0.001), but similar among those on anticoagulants (P > 0.05). In patients with sinus rhythm, the associations between SEC/LVT and ischaemic stroke persist with HRs of 2.57 (95% CI: 1.69–3.92) and 5.74 (95% CI: 3.38–9.75).

Conclusions

In patients with HFrEF, SEC was not uncommon and increased risk of ischaemic stroke as well as LVT. Anticoagulants could play a role in the reduction of stroke risk, suggesting that patients with SEC/LVT, even those in sinus rhythm, would benefit from systemic anticoagulation treatment.

Outcomes of left ventricular thrombosis in post-acute myocardial infarction patients stratified by antithrombotic strategies: A meta-analysis with meta-regression

BACKGROUND

Left ventricular thrombus (LVT) formation is a significant complication of acute myocardial infarction (AMI) due to its embolic potential. However, managing LVT requires balancing therapeutic benefits against bleeding risks. Our study provides a risk-benefit analysis of various antithrombotic regimens on long-term outcomes in treating post-AMI LVT patients.

METHODS

We conducted a comprehensive literature search in Medline, Embase and SCOPUS up to 1 April 2020. All studies reporting outcomes of post-AMI LVT patients were included.

RESULTS

17 studies were included in total. Anticoagulation (47-100%) and triple therapy use (38-100%) varied largely across studies. On meta-analysis, administration of anticoagulation (OR 0.14, 95% CI 0.05-0.36, p < 0.001) and triple therapy (OR 0.22, 95% CI 0.07-0.66, p < 0.001) resulted in lower odds of mortality. Neither anticoagulation (p = 0.24) nor triple therapy (p = 0.73) was associated with bleeding. Triple therapy was associated with LVT resolution on meta-analysis (OR 2.53, 95% CI 1.53-4.19, p < 0.001) and regression analysis (OR 1.28, 95% CI 1.03-1.58, p = 0.03). Anticoagulation and triple therapy were independent predictors of systemic embolism ([OR 0.67, 95% CI 0.49-0.93, p = 0.02] and [OR 0.82, 95% CI 0.73-0.93, p = 0.001]) and stroke ([OR 0.62, 95% CI 0.41-0.94, p = 0.03] and [OR 0.73, 95% CI 0.55-0.96, p = 0.03]).

CONCLUSIONS

While there is clear therapeutic benefit in anticoagulation for post-AMI LVT, the extent of bleeding risk is uncertain. Future trials are necessary to determine the optimal antithrombotic strategy for post-AMI LVT management.

Predicting mortality, thrombus recurrence and persistence in patients with post-acute myocardial infarction left ventricular thrombus

Left ventricular thrombus (LVT) is a common complication of acute myocardial infarction and is associated with morbidity from embolic complications. Predicting which patients will develop death or persistent LVT despite anticoagulation may help clinicians identify high-risk patients. We developed a random forest (RF) model that predicts death or persistent LVT and evaluated its performance. This was a single-center retrospective cohort study in an academic tertiary center. We included 244 patients with LVT in our study. Patients who did not receive anticoagulation (n = 8) or had unknown (n = 31) outcomes were excluded. The primary outcome was a composite outcome of death, recurrent LVT and persistent LVT. We selected a total of 31 predictors collected at the point of LVT diagnosis based on clinical relevance. We compared conventional regularized logistic regression with the RF algorithm. There were 156 patients who had resolution of LVT and 88 patients who experienced the composite outcome. The RF model achieved better performance and had an AUROC of 0.700 (95% CI 0.553-0.863) on a validation dataset. The most important predictors for the composite outcome were receiving a revascularization procedure, lower visual ejection fraction (EF), higher creatinine, global wall motion abnormality, higher prothrombin time, higher body mass index, higher activated partial thromboplastin time, older age, lower lymphocyte count and higher neutrophil count. The RF model accurately identified patients with post-AMI LVT who developed the composite outcome. Further studies are needed to validate its use in clinical practice.

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

BACKGROUNDS

The prognosis and management of left ventricular thrombus (LVT) following acute myocardial infarction (AMI) have not been well evaluated since the advent of primary percutaneous coronary intervention (PCI). We therefore conducted a meta-analysis to assess the prognostic effect of LVT after AMI in primary PCI era and investigate the impact of triple therapy on outcomes.

METHODS

We searched MEDLINE, EMBASE and the Cochrane Library for studies conducted in primary PCI era up to 29 March 2019, compering the incidence of embolic events and mortality after AMI between LVT patients and Non-LVT patients. Random-effect models were used. Subgroup analysis was done by comparing triple therapy treated LVT group with Non-LVT group.

RESULT

A total of 12 studies were included. LVT was associated with increased risk of embolic events and long-term mortality (RR 3.97, 95%CI 2.68-5.89, P < 0.0001; RR 2.34, 95%CI 1.38-3.96, P = 0.002). Subgroup analysis was also done by comparing triple therapy treated LVT group with Non-LVT group. Despite a downward tendency was observed, the embolic risk of triple therapy subgroup was higher than non-LVT group (RR 2.79, 95%CI 1.32-5.91, P = 0.007). Triple therapy subgroup had a similar mortality rate compared with non-LVT group (RR 0.93, 95%CI 0.34-2.52, P = 0.88).

CONCLUSION

In primary PCI era, LVT formation after AMI indicated a fourfold increased embolic risk and twofold long-term mortality rate. Triple therapy may be a safe way to improve the outcomes, but still need to be confirmed by future trials.

Left Ventricular Thrombus in Myocardial Infarction After Successful Primary Percutaneous Coronary Intervention: Prevalence and Predictors-A Middle Eastern Single-Centre Experience

Background

Left ventricular thrombus (LVT) is a well-recognized complication of myocardial infarction that affects patient outcomes and warrants screening.

Methods

This retrospective study included 308 consecutive patients who presented with acute ST-elevation myocardial infarction and were treated with primary percutaneous coronary intervention.

Results

Early screening for LVT by echocardiography and cardiac magnetic resonance revealed the following: LVT (+) group (36 patients [11.7%]) and LVT (−) group (272 patients [88.3%]). The 2 powerful independent variables associated with LVT formation were left anterior descending–related infarct (odds ratio, 10.17; P < 0.0001) and severe left ventricular systolic dysfunction (odds ratio, 8.3; P = 0.0001). The lower the left ventricular ejection fraction, the higher the risk of LVT was. Multivessel coronary artery disease and the type of early invasive strategy (culprit lesion only vs complete revascularization) were not predictive of LVT. The impact of environment (i.e., hot climate, exercise) and dehydration on the risk of LVT formation is uncertain.

Conclusion

Early LVT formation is a frequent complication in acute ST-elevation myocardial infarction despite timely intervention. Its independent predictors are left anterior descending–related infarct and severe left ventricular systolic dysfunction. In patients with multivessel coronary artery disease, there was no significant difference between lesion-only culprits and complete revascularization in reducing the risk of LVT development. Further studies in larger numbers of patients are needed because of the uncertainties regarding the links between the biological effects of the environment and the risk of LVT formation.

The effect of ticagrelor based dual antiplatelet therapy on development of late left ventricular thrombus after acute anterior ST elevation myocardial infarction

AIM

The aim of this study is to investigate the impact of ticagrelor as compared to clopidogrel based dual antiplatelet therapy (DAPT) during post-discharge management on the incidence of left ventricular (LV) thrombus in patients with first acute anterior ST elevation myocardial infarction (STEMI).

METHOD

641 patients who met the inclusion criteria were divided into two groups based on the receipt of either ticagrelor or clopidogrel based DAPT.

RESULT

Left ventricular thrombus was detected in 73 (11.4%) patients at the first month echocardiographic examination. Ticagrelor based DAPT was associated with significantly less incidence of LV thrombus when compared to clopidogrel [20 (7.4%) vs 53 (14.0%) OR: 0.50 (0.29-0.86)]. Penalized maximum likelihood estimation (PMLE) logistic regression analyses were performed to fourteen candidate variables for identifying the independent predictors of LV thrombus, ticagrelor (compared with clopidogrel) [OR: 0.53 (0.28-0.96), p = 0.039], body mass index (BMI) [OR: 0.58 (0.44-0.77), p < 0.001], KILLIP class (I vs II-IV) [OR: 0.35 (0.14-0.83), p = 0.017], age [OR: 1.22 (1.08-1.40), p < 0.001], poor postprocedural myocardial blush grade (MBG) [OR: 3.35 (1.32-8.15), p = 0.012] and LVEF predischarge [OR: 0.79 (0.72-0.86), p < 0.001] were found to be associated with LV thrombus.

CONCLUSION

Our study demonstrated that the incidence of LV trombus was significantly lower with ticagrelor than clopidogrel-based DAPT during postdischarge treatment for anterior STEMI patients.

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Background

Left ventricular (LV) thrombi during Takotsubo syndrome represent a potential complication and can be associated with cerebrovascular embolic events. The aim of this study was to evaluate the exact incidence, predictors, and management strategies of LV thrombi in patients with Takotsubo syndrome.

Methods and Results

We enrolled 541 consecutive patients in a multicenter international registry. Clinical features and echocardiographic data at admission, during hospitalization, and after 3 months were evaluated. Survival rates for long‐term follow‐up (mean 984±908 days) were recorded. Twelve Takotsubo syndrome patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern). All patients with LV thrombi were treated with oral anticoagulation therapy; however, 2 (17%) had a stroke before treatment initiation. These patients were characterized by a higher prevalence of ST‐elevation (56% versus 16%; P<0.001) and higher troponin I levels (10.8±18.3 ng/mL versus 3.5±4.3 ng/mL; P=0.001) as compared with those without LV thrombi. At multivariate analysis including age, sex, LV ejection fraction, ST‐elevation at admission, and apical ballooning pattern, troponin I level >10 ng/mL was the only predictor for LV thrombosis (hazard ratio 6.6, confidence interval, 1.01–40.0; P=0.04). After 3 months all LV thrombi disappeared. Oral anticoagulation therapy was interrupted in all patients except 1. At long‐term follow‐up, the survival rate was not different between patients with and without LV thrombi (84% versus 85%; P=0.99).

Conclusions

LV thrombi have a relatively low incidence among patients with Takotsubo syndrome and were detected in female patients with apical ballooning pattern and increased troponin levels. Oral anticoagulation therapy for 3 months seems reasonable in these high‐risk patients.

[Prethrombus acute constitution during dobutamine stress echocardiography]

Although generally regarded as a safe stress modality, dobutamine stress echocardiography (DSE) has been associated with several well described complications. However, to our knowledge, acute constitution of thrombi during the stress test has never been described. In this report, we present the case of a 64 year-old man with a history of ischemic heart disease who underwent a preoperative DSE; during the test, we witnessed a striking acute constitution of an intense prethrombotic state with almost a formation of a highly mobile massive thrombus adjacent to the infero-apical segment spontaneously resolving few minutes after the end of the test.

Ischemic Stroke Risk After Acute Coronary Syndrome

BACKGROUND

Prior studies show an increased risk of ischemic stroke (IS) after myocardial infarction; however, there is limited evidence on long-term risk and whether it is directly related to cardiac injury. We hypothesized that the risk of IS after acute coronary syndrome is significantly higher if there is evidence of cardiac injury, such as ST-segment elevation myocardial infarction (STEMI) or non-STEMI, than when there is no evidence of cardiac injury, such as in unstable angina.

METHODS AND RESULTS

Administrative claims data were obtained from all emergency department encounters and hospitalizations at California's nonfederal acute care hospitals between 2008 and 2011. Patients with STEMI, non-STEMI, and unstable angina were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. The primary outcome was IS during 2 years of follow-up. Unadjusted and adjusted Cox proportional hazards models were used to determine the association between acute coronary syndrome subtype and IS risk. We identified 73 059 patients with a diagnosis of STEMI (n=26 427), non-STEMI (n=39 833), or unstable angina (n=6819) during the study period. In the fully adjusted models that included potential confounders such as atrial fibrillation and congestive heart failure, the risk of IS was higher with STEMI (hazard ratio 4.17, 95% CI 3.00-5.83; P<0.001) and non-STEMI (hazard ratio 3.73, 95% CI 2.68-5.19, P<0.001) compared with unstable angina.

CONCLUSIONS

Non-STEMI and STEMI confer an equally increased risk of IS. Studies exploring IS mechanisms in cardiac patients are needed to improve and tailor stroke prevention strategies.

Delayed left ventricular apical thrombus formation following discontinuation of dual anti-platelet therapy

Delayed de novo left ventricular apical thrombus following a distant antero-apical myocardial infarction has to our knowledge not been previously reported. Herein we describe a patient who developed an apical thrombus 18 months after his initial infarct following cessation of dual anti-platelet therapy for a traumatic subdural haematoma requiring surgical evacuation.

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

INTRODUCTION

Left ventricular (LV) thrombi carry a high risk of embolization. Therapeutic recommendations like treatment with low molecular heparin and intravenous unfractionated heparin (UFH), thrombolysis or surgical thrombectomy have failed to reach a consensus.

CASE DESCRIPTION

A 56-year-old female patient presented in cardiogenic shock to the emergency department. Echocardiography demonstrated a dilated LV with a severely depressed global systolic function and a large LV apical thrombus. Treatment with UFH was initiated as well as a treatment with catecholamines for stabilizing the patient's hemodynamic situation. On the follow-up echocardiographic examination, extensive free-floating parts of the thrombus could be documented. Given the high risk of embolization in a now hemodynamically stable situation, emergency surgical embolectomy was performed.

DISCUSSION

A conservative procedure might be useful for bridging till surgical treatment is available and/or the risk due to surgery is acceptable.

CONCLUSION

In absence of evidence-based guidelines for the treatment of LV thrombi, individualized management options concerning surgical, embolization and bleeding risk must be taken into account.

SYNTAX Score Predicts the Left Ventricle Thrombus Development in Patients Undergoing Primary Percutaneous Coronary Intervention for First Anterior Myocardial Infarction

Objectives:

The aim of this study is to investigate the relationship between left ventricular thrombus (LVT) developments and the SYNTAX score (SS) in patients undergoing primary percutaneous coronary intervention (PPCI) for first anterior wall ST-segment elevation myocardial infarction (STEMI).

Methods:

We enrolled 160 patients. All participants were evaluated by serial transthoracic echocardiography. Baseline clinical, echocardiographic, and procedural features of PPCI were analyzed to find predictors of LVT development.

Results:

The LVT was detected in 32 (20%) patients. Left ventricular ejection fraction (LVEF) and SS-I were found to be independent predictors of LVT development. Receiver–operating characteristic curve analysis revealed a cutoff value >19.5 for SS-I (area under the curve: 0.697, 95% confidence interval 0.620-0.767, P < .001) with a specificity of 45.3% and a sensitivity of 84.3%.

Conclusion:

High SS which was obtained through diagnostic angiogram of PPCI may be associated with LVT development in patients with first anterior wall STEMI.

Prothrombotic markers in patients with acute myocardial infarction and left ventricular thrombus formation treated with pci and dual antiplatelet therapy

Background

The aim of the present study was to compare circulating levels of selected prothrombotic markers in patients suffering acute myocardial infarction (AMI) with and without left ventricular (LV) thrombus.

Methods

One hundred patients with AMI treated with PCI on the LAD and dual antiplatelet therapy were included. LV thrombus formation was detected by echocardiography and/or MRI in 15 patients. Fasting blood samples were drawn 4–5 days (baseline), 6–7 days, 8–9 days, 2–3 weeks and 3 months after the AMI for determination of haemostatic markers.

Results

We found higher levels of soluble tissue factor (TF) and D-dimer in the LV thrombus group 4–5 days, 8–9 days and 3 months (only TF) after the AMI compared to the patients without thrombus formation (p<0.05). Patients with TF in the upper quartile at baseline had significantly higher risk for LV thrombus (OR 4.2; 95% CI 1.2 -14.5; p=0.02, adjusted for infarct size).

The levels of prothrombin fragment 1+2 (F1+2) and endogenous thrombin potential (ETP) were significantly lower in the thrombus group after 8–9 days (only ETP), 2–3 weeks and 3 months. The levels of plasminogen activator inhibitor 1 activity and tissue plasminogen activator antigen did not differ between the groups.

Conclusion

In the acute phase of AMI, we found higher levels of TF and D-dimer in the LV thrombus group, indicating hypercoagulability of possible importance for the generation of mural thrombus. Lower levels of F1+2, ETP and D-dimer in the thrombus group late during follow-up are probably induced by the initiated anticoagulation therapy.

Risk factors for development of left ventricular thrombus after first acute anterior myocardial infarction-association with anticardiolipin antibodies

Background

Left ventricular thrombus(LVT] formation is a frequent complication in patients with acute anterior myocardial infarction(MI). LVT is associated with increased risk of embolism and higher mortality rates after acute MI. Anticardiolipin antibodies (ACA) are immunoglobulins that react with phospholipid-binding proteins interfering with the prothrombin activator complex. The effects of phospholipids on pathophysiology of cardiovascular thrombotic events are well known. In this study, we aimed to evaluate the importance of clinical and biochemical parameters including anticardiolipin antibodies on left ventricular thrombus formation after acute anterior MI.

Methods and Results

Seventy patients with a first anterior AMI were prospectively and consecutively enrolled. Patients with previous MI, autoimmune disease, collagen vascular disease and arterial or venous thrombosis history were excluded from this study. At the time of hospitalization, key demographic and clinical characteristics were collected including age, gender, ethanol intake and presence of traditional risk factors for atherosclerosis (hypertension, diabetes, smoking, hyperlipidemia, positive family history). Patients were evaluated for echocardiographic data, blood chemistry and ACA. Two-dimensional and Doppler echocardiographic examinations were performed in all patients within the first week and at 14 days after MI. LV thrombus was detected in 30 (42.8%) patients. ACA IgM levels were significantly higher in the patient group with LV thrombus than in the group without thrombus (12.44 ±4.12 vs. 7.69 ± 4.25 mpl, p = 0,01). ACA IgG levels were also found higher in the group with LV thrombus (24.2 ± 7.5 vs.17.98 ± 6.45 gpl, p = 0.02). Multivariate analyses revealed diabetes mellitus, higher WMSI, lower MDT and higher ACA IgM and higher ACA IgG levels as independent predictors of left ventricular thrombus formation.

Conclusions

Our data demonstrate that beside the low ejection fraction, lower MDT and higher wall motion score index, modestly elevated ACA IgM and ACA IgG levels are associated with LV thrombus formation in patients with anterior MI.

Incidence of early left ventricular thrombus after acute anterior wall myocardial infarction in the primary coronary intervention era

BACKGROUND

Rapid reperfusion has been shown to decrease mortality and improve left ventricular (LV) function. Previous studies have reported that LV thrombus (LVT) is a major complication of ST-segment elevation acute anterior wall myocardial infarction (AMI). There are little data on LVT in the current primary percutaneous coronary intervention (PPCI) era. We sought to demonstrate the incidence of LVT after AMI in patients treated with PPCI compared with those treated with thrombolysis or with conservative management.

METHODS

In a 6-year period, 642 patients with anterior wall AMI and echocardiography were treated with PPCI (n = 297), thrombolysis (n = 128), or conservative treatment (n = 217). Left ventricular thrombus was defined as an echodense mass adjacent to an abnormally contracting myocardial segment.

RESULTS

The rate of LVT among anterior wall AMI was 6.2%. Predictors for LVT were reduced ejection fraction (adjusted relative risk 0.71, 95% CI 0.52-0.96) and severe mitral regurgitation (adjusted relative risk 2.48, 95% CI 1.0-6.44). There was no statistical difference in LVT rate according to treatment: 21 (7.1%) of 297 patients in the PPCI group, 10 (7.8%) of 128 patients in the thrombolytic group, and 9 (4.1%) of 217 patients in the conservative group (P = .28). Those in the thrombolytic group were characterized by shorter duration from symptom onset and were generally also treated with heparin/low-molecular weight heparin.

CONCLUSIONS

This is the largest report to evaluate the incidence of LVT formation after AMI. In the current era of rapid reperfusion by PPCI, the rate of thrombus formation is similar to that reported in the past and not different than for patients currently treated conservatively or with thrombolysis.

Plasma homocysteine level and left ventricular thrombus formation in acute anterior myocardial infarction patients following thrombolytic therapy with t-PA

AIMS

The aim of this study was to evaluate the relationship between homocysteine levels and the development of left ventricular thrombus in acute anterior myocardial infarction patients directed to thrombolytic therapy.

METHODS AND RESULTS

Seventy-nine patients presenting with ST elevated acute anterior myocardial infarction and treated with thrombolytic agent, t-PA, were included in the study. Two-dimensional echocardiography was used to divide patients into 2 groups according to the presence (n = 14) or absence (n = 65) of thrombus in the left ventricle following myocardial infarction. The levels of fasting plasma total homocysteine, total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, vitamin B12 and folic acid were assessed. There were no significant differences between two groups in terms of age, gender, hyperlipidemia and smoking. History of diabetes mellitus (28.57% versus 6.15%, p = 0.04), peak creatine phosphokinase levels (4153.54 +/- 1228.41 U/L versus 2456.92 +/- 1421.36 U/L, p < 0.001), mean left ventricular wall motion score index (2.21 +/- 0.18 versus 1.83 +/- 0.23, p < 0.001) and total fasting homocysteine levels (18.24 +/- 5.67 mmol/L versus 12.31 +/- 3.52 mmol/L, p < 0.001) were significantly higher in patients with left ventricular thrombus. In multivariate analysis; only diabetes mellitus (p = 0.03), higher wall motion score index (p = 0.001) and higher homocysteine levels (p = 0.04) were independent predictors of left ventricular thrombus formation.

CONCLUSION

Our results suggest that; diabetes mellitus, higher wall motion score index and hyperhomocysteinemia independently increases the risk for the development of left ventricular thrombus formation in patients with acute anterior myocardial infarction following thrombolytic therapy.

Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation

BACKGROUND

Left ventricular (LV) thrombus is a frequent and potentially dangerous complication of ischemic heart disease (IHD). We evaluated the clinical, imaging, and pathology characteristics of confirmed LV thrombus and compared the diagnostic value of contrast-enhanced magnetic resonance imaging (MRI) with transthoracic (TTE) and transesophageal echocardiography (TEE) for the diagnosis of LV thrombi.

METHODS

Between November 1997 and December 2003, 361 patients with IHD had surgical and/or pathological confirmation of presence or absence of LV thrombus. Clinical information and preoperative imaging study reports were retrospectively reviewed regarding detection of thrombus. Comparisons were made between clinical and imaging characteristics of patients with and without confirmed thrombus.

RESULTS

Left ventricular thrombus was present in 106 (29%) of 361 patients in this study. Patients with thrombus had a higher incidence of recent embolic events (6.1% vs 0.8%, P < .005). In 160 patients with all 3 imaging modalities performed within 30 days of surgical or pathological confirmation, contrast-enhanced MRI showed the highest sensitivity and specificity (88% +/- 9% and 99% +/- 2%, respectively) compared with TTE (23% +/- 12% and 96% +/- 3.6%, respectively) and TEE (40% +/- 14% and 96% +/- 3.6%, respectively) for thrombus detection.

CONCLUSIONS

Left ventricular thrombus occurs frequently in patients with IHD and is associated with risk of systemic embolization. Contrast-enhanced MRI provided the highest sensitivity and specificity for LV thrombus when compared to TTE and TEE, and should be considered in the care of patients at high risk of LV thrombus formation.

Relation between early mitral regurgitation and left ventricular thrombus formation after acute myocardial infarction: results of the GISSI-3 echo substudy

OBJECTIVE

To evaluate the prevalence and correlates of left ventricular thrombosis in patients with acute myocardial infarction, and whether the occurrence of early mitral regurgitation has a protective effect against the formation of left ventricular thrombus.

DESIGN AND SETTING

Multicentre clinical trial carried out in 47 Italian coronary care units.

PATIENTS AND METHODS

757 patients from the GISSI-3 echo substudy population with their first acute myocardial infarct were studied by echocardiography at 24-48 hours from symptom onset (S1), at discharge (S2), at six weeks (S3), and at six months (S4). The diagnosis of left ventricular thrombosis was based on the detection of an echo dense mass with defined margins visible throughout the cardiac cycle in at least two orthogonal views.

RESULTS

In 64 patients (8%), left ventricular thrombosis was detected in one or more examinations. Compared with the remaining 693 patients, subjects with left ventricular thrombosis were older (mean (SD) age: 64.6 (13.0) v 59.8 (11.7) years, p < 0.005), and had larger infarcts (extent of wall motion asynergy: 40.9 (11.5)% v 24.9 (14)%, p < 0.001), greater depression of left ventricular ejection fraction at S1 (43.3 (6.9)% v 48.1 (6.8)%, p < 0.001), and greater left ventricular volumes at S1 (end diastolic volume: 87 (22) v 78 (18) ml/m(2), p < 0.001; end systolic volume: 50 (17) v 41 (14) ml/m(2), p < 0.001). The prevalence of moderate to severe mitral regurgitation on colour Doppler at S1 was greater in patients who had left ventricular thrombosis at any time (10.2% v 4.2%, p < 0.05). On stepwise multiple logistic regression analysis the only independent variables related to the presence of left ventricular thrombosis were the extent of wall motion asynergy and anterior site of infarction.

CONCLUSIONS

Left ventricular thrombosis is not reduced, and may even be increased, by early moderate to severe mitral regurgitation after acute myocardial infarction. The only independent determinant of left ventricular thrombosis is the extent of the akinetic-dyskinetic area detected on echocardiography between 24-48 hours from symptom onset.

A giant left ventricular thrombus in a patient with acute myocardial infarction--a case report

The authors report a patient with acute anteroseptal myocardial infarction with a giant left ventricular thrombus at the apex. The patient also had nephrotic syndrome due to diabetic nephropathy. Coronary angiography showed 90% stenosis at segment 6 of the left anterior descending coronary artery. Percutaneous transluminal coronary angioplasty and intracoronary stenting were performed on the 30th day, and effective coronary blood flow was obtained. Heparin was injected intravenously for the first 7 days, and warfarin was administered thereafter. The left ventricular thrombus disappeared after 46 days. No evidence of arterial thromboembolism was found during the disappearance of the left ventricular thrombus as determined by echocardiography.

Predictors of left ventricular thrombus formation in patients with anterior myocardial infarction: role of activated protein C resistance

BACKGROUND

Left ventricular mural thrombus formation is a well-recognised consequence of acute anterior myocardial infarction. The vast majority of left ventricular thromboses occur in patients with anterior myocardial infarction and depressed left ventricular function.

OBJECTIVE

To evaluate the factors predicting left ventricular thrombus formation in patients similar for left ventricular function and left ventricular score indexes.

METHODS

We evaluated 45 consecutive patients who met the inclusion criteria of anterior myocardial infarction resulting in apical, anterior or septal asynergy (akinesia, dyskinesia), without non-Q-wave myocardial infarction, dilated cardiomyopathy, or renal or hepatic dysfunction. Patients were divided into two groups: group I with, and group II without, left ventricular mural thrombus. The groups were compared for clinical, echocardiographic and hematologic parameters (activated protein C resistance (APC-R), protein S and antithrombin III).

RESULTS

Smoking and ACP-R were significantly greater in group I than in group II (P < 0.05 and P < 0.005 respectively). Multivariate regression analysis showed that APC-R was an independent risk factor for left ventricular thrombus formation in the patient group selected. Antithrombin III and protein S concentrations were not statistically different between two groups. All other clinical and echocardiographic characteristics of the patients were similar in both groups.

CONCLUSION

APC-R is an independent risk factor for left ventricular thrombosis in patients with anterior myocardial infarction resulting in septal or anterior and apical akinesia or dyskinesia.