Rarecase of biventricular thrombi complicating pulmonary embolism

Direct Oral Anticoagulants Versus Warfarin for the Treatment of Left Ventricular Thrombus: A Multicenter Retrospective Observational Study

Vitamin K antagonists remain the mainstay of therapy in patients with left ventricular thrombus (LVT) because the efficacy of direct oral anticoagulants (DOACs) is not well-established. We performed a multicenter retrospective analysis of adults admitted between January 2015 and December 2021 and diagnosed with LVT to compare the safety and efficacy of warfarin versus DOACs. The primary outcome was thrombus resolution. Secondary outcomes included all-cause mortality, bleeding events, and stroke or systemic embolism. A total of 189 patients were included. The rate of thrombus resolution was similar in patients with LVT treated with DOACs compared with those treated with warfarin (DOACs 73.9%vs warfarin 68.5%, p = 0.489). In addition, all-cause mortality (DOACs 13.04% vs warfarin 9.79%, p = 0.583), bleeding events (DOACs 19.57% vs warfarin 13.99%, p = 0.361), and stroke or systemic embolism (DOACs 10.87% vs warfarin 15.38%, p = 0.446) were all similar in the 2 groups. In the propensity-matched group, 90 patients were included. Multivariate analysis showed no significant difference of using warfarin or DOACs on thrombus resolution (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.858 to 1.029, p = 0.18), all-cause mortality (OR 1.032, 95% CI 0.906 to 1.176, p = 0.6354), bleeding events (OR 1.694, 95% CI 0.168 to 17.097, p = 0.655), or stroke or systemic embolism (OR 1.947, 95% CI 0.087 to 4.756, p = 0.6747). In conclusion, in our retrospective analysis, DOACs had similar efficacy and safety compared with warfarin in the treatment of LVT.

Massive Biventricular Thrombi in a Patient with Endometrial Adenocarcinoma Diagnosed on Computed Tomography Angiography

Biventricular thrombi are a rare clinical entity and only reported in several case reports. Given ventricular thrombi are high risk for cardioembolic events, accurate detection and therapeutic management has an important influence on clinical outcomes. We present a case of a patient with biventricular thrombi that was initially diagnosed on computed tomography angiography, emphasizing its clinical utility as a rapid, non-invasive imaging modality for early detection.

Extensive aortic thrombosis and testicular infarction – a rare complication of biventricular cardiac thrombi

Heart failure is a heterogenous syndrome which is increasing in prevalence, with a prognosis worse than many malignancies. Morbidity and mortality most commonly occur secondary to pump failure or ventricular arrhythmias; however, a more infrequently seen complication is the formation of mural thrombi. More commonly seen within the left ventricle, thrombi can embolize leading to stroke or end organ infarction. We present the case of a male who presented with decompensated heart failure. The presence of biventricular thrombi was found on echocardiography and subsequent cross-sectional imaging revealed these had embolized resulting in the rare complication of extensive abdominal aortic thrombosis with renal and testicular infarction. Biventricular thrombi are rare but high risk due to the potential for embolization as demonstrated in this case. Prompt recognition and management with anti-coagulation are essential, followed by treatment of the underlying pathology, which resulted in the formation of thrombi to prevent recurrence.

The Role of Direct Oral Anticoagulants Versus Vitamin K Antagonists in the Treatment of Left Ventricular Thrombi: A Meta-Analysis and Systematic Review

BACKGROUND

Direct oral anticoagulants (DOACs) have a well-established role in the treatment of deep vein thrombosis and pulmonary embolism and in the reduction of thromboembolism in nonvalvular atrial fibrillation. However, limited evidence supports their role in patients with left ventricular thrombi.

METHODS

The PubMed, EMBASE, and Cochrane databases were searched for relevant articles published from inception to 1 August 2020. We included studies evaluating the effect of DOACs versus vitamin K antagonists (VKAs) in patients with left ventricular thrombi. The primary outcome was thrombus resolution, and the secondary outcomes were major bleeding and stroke or systemic embolization (SSE).

RESULTS

Five retrospective observational studies were included, with a total of 857 patients. VKAs and DOACs had a similar rate of thrombus resolution (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.57-1.65; p = 0.90). Our analysis also demonstrated a similar rate of major bleeding (OR 0.62; 95% CI 0.27-1.44; p = 0.27) and SSE (OR 1.86; 95% CI 0.99-3.50; p = 0.05) between the two treatment groups.

CONCLUSION

In patients with left ventricular thrombi, DOACs and VKAs are associated with similar rates of thrombus resolution, major bleeding, and SSE.

Will Direct Oral Anticoagulants Have a Chance in Prosthetic Valves?

Although there are abundant data highlighting the safety and efficacy of direct oral anticoagulants, to date, recent guidelines have limited their use to stroke prevention in patients with non-valvular AF, as well as in the prevention and treatment of venous thromboembolism and pulmonary embolism. Encouraging data about the off-label use of direct oral anticoagulants have been shown in several other indications, such as intracardiac thrombi, left ventricular thrombi and left atrial appendage, but a large sector of patients are still not addressed, such as valvular and prosthetic patients.