Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge

Comparison of embolic risk in left ventricular thrombus between nonischemic and ischemic cardiomyopathy: A nationwide database analysis

BACKGROUND

Left ventricular (LV) thrombus is not common but poses significant risks of embolic stroke or systemic embolism. However, the distinction in embolic risk between nonischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM) remains unclear.

METHODS AND RESULTS

In total, 2738 LV thrombus patients from the JROAD-DPC (Japanese Registry of All Cardiac and Vascular Diseases Diagnosis Procedure Combination) database were included. Among these patients, 1037 patients were analyzed, with 826 (79.7%) having ICM and 211 with NICM (20.3%). Within the NICM group, the distribution was as follows: dilated cardiomyopathy (DCM; 41.2%), takotsubo cardiomyopathy (27.0%), hypertrophic cardiomyopathy (18.0%), and other causes (13.8%). The primary outcome was a composite of embolic stroke or systemic embolism (SSE) during hospitalization. The ICM and NICM groups showed no significant difference in the primary outcome (5.8% vs. 7.6%, p = 0.34). Among NICM, SSE occurred in 12.6% of patients with DCM, 7.0% with takotsubo cardiomyopathy, and 2.6% with hypertrophic cardiomyopathy. Multivariate logistic regression analysis for SSE revealed an odds ratio of 1.4 (95% confidence interval [CI], 0.7-2.7, p = 0.37) for NICM compared to ICM. However, DCM exhibited a higher adjusted odds ratio for SSE compared to ICM (2.6, 95% CI 1.2-6.0, p = 0.022).

CONCLUSIONS

This nationwide shows comparable rates of embolic events between ICM and NICM in LV thrombus patients, with DCM posing a greater risk of SSE than ICM. The findings emphasize the importance of assessing the specific cause of heart disease in NICM, within LV thrombus management strategies.

Clinical Phenotypes and Outcomes of Patients with Left Ventricular Thrombus: An Unsupervised Cluster Analysis

BACKGROUND

Left ventricular thrombus (LVT) can develop in a diverse group of patients with various underlying causes resulting in divergent natural histories and trajectories with treatment. Our aim was to utilise cluster analysis to identify unique clinical profiles among LVT patients and then compare their clinical characteristics, treatment strategies, and outcomes.

METHODS

We conducted a retrospective study involving 472 LVT patients whose data was extracted from a tertiary center's echocardiography database, from March 2011 to January 2021. We employed the TwoStep cluster analysis method, examining 19 variables.

RESULTS

Our analysis of the 472 LVT patients revealed two distinct patient clusters. Cluster 1, comprising 247 individuals (52.3%), was characterized by younger patients with a lower incidence of traditional cardiovascular risk factors and relatively fewer comorbidities, compared to Cluster 2. Most patients had LVT attributed to an underlying ischaemic condition, with a larger proportion in Cluster 1 being due to post-acute myocardial infarction (68.8%), and Cluster 2 due to ischaemic cardiomyopathy (57.8%). Notably, patients in Cluster 2 exhibited a reduced likelihood of LVT resolution (HR 0.58, 95% CI 0.44 - 0.77, p < 0.001) and a higher risk of all-cause mortality (HR 2.27, 95% CI 1.43 - 3.60, p = 0.001). These associations persisted even after adjusting for variables like anticoagulation treatment, the presence of left ventricular aneurysms, and specific LVT characteristics such as mobility, protrusion, and size.

CONCLUSIONS

Through TwoStep cluster analysis, we identified two distinct clinical phenotypes among LVT patients, each distinguished by unique baseline clinical attributes and varying prognoses.

Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Treatment of Left Ventricular Thrombi-Insights from a Swiss Multicenter Registry

Current guidelines recommend vitamin K antagonists (VKAs) for the treatment of a left ventricular thrombus (LVT). However, direct oral anticoagulants (DOACs) show superior safety and efficacy compared with VKAs in most thromboembolic disorders. Nevertheless, DOACs remain poorly investigated for the treatment of LVT. To describe the thrombus resolution rate and clinical efficacy of DOACs versus VKAs in patients with LVT, we analyzed consecutive patients with confirmed LVT from a multicenter echocardiography database. Echocardiograms and clinical end points were evaluated independently. The thrombus resolution rate and clinical outcomes were compared according to the underlying anticoagulation regimen. In total, 101 patients were included (17.8% women, mean age 63.3 ± 13.2 years), 50.5% had recently experienced a myocardial infarction. The mean left ventricular ejection fraction was 36.6 ± 12.2%. DOACs versus VKAs were used in 48 and 53 patients, respectively. The median follow-up was 26.6 (interquartile range 11.8;41.2) months. Among patients receiving VKAs compared with DOACs, the thrombus resolved more rapidly within the first month in those taking VKAs (p = 0.049). No differences were seen between the 2 groups with respect to major bleedings, strokes, and other thromboembolic events. In each group, LVT recurred in 3 of the subjects (a total of 6) after discontinuation of anticoagulation. In conclusion, DOACs appear to be a safe and effective alternative to VKAs for the treatment of LVTs, but the rate of thrombus dissolution within 1 month after initiation of anticoagulation appears to be higher with VKAs. A sufficiently powered randomized trial is required to definitively define the role of DOACs in the treatment of LVT.

Novel subgroups of patients with left ventricular thrombus and their differential effects with anticoagulation: a data-driven cluster analysis (Preprint)

UNSTRUCTURED

Ahead of Print article withdrawn by the publisher.

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.