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Sacoransky E, Yu Jia Ke D, Dave P, Alexander B, El Sherbini A, Abunassar J, Abuzeid W. Incidence of left ventricular thrombus following STEMI in the modern era via multimodality imaging: A systematic review and meta-analysis. Int J Cardiol Heart Vasc 2024; 52:101396. [PMID: 38584672 PMCID: PMC10992728 DOI: 10.1016/j.ijcha.2024.101396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
Background Left ventricular thrombus (LVT) is a significant complication in STEMI. Previous studies were conducted prior to modern timely percutaneous reperfusion networks. Current expert opinion suggests incidence in the current era has decreased. We conducted a systematic review and meta-analysis to better understand the incidence and diagnosis of LVT in patients with STEMI treated with timely percutaneous techniques as assessed by multimodality imaging. Methods Cochrane, EMBASE, LILACS, and MEDLINE were searched over the last 10 years only including studies using contemporary techniques. The primary outcome was detection of LVT in patients via echocardiogram with or without contrast or Cardiac MRI (cMRI) following STEMI (both anterior and any territory) treated with PCI. Data was pooled across studies and statistical analysis was conducted via random effects model. Results 31 studies were included. 18 studies included data on any territory STEMI, totaling 14,172 patients, and an incidence of 5.6% [95% CI 4.3-7.0]. 18 studies were included in analysis for anterior STEMI, totaling 7382 patients and incidence of 12.7% [95% CI 9.8-15.6]. Relative to cMRI as a gold standard, the sensitivity of non-contrast echocardiography to detect LVT was 58.2% [95% CI 46.6-69.2] with a specificity of 97.8% [95% CI 96.3-98.8]. Conclusions Incidence of LVT in STEMI patients treated with contemporary timely percutaneous revascularization is in keeping with historical data and remains significant, suggesting this remains an ongoing issue for further investigation. Numerically, both cMRI and contrast echo detected more LVT compared to non-contrast echo in any-territory STEMI patients.
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Affiliation(s)
| | - Danny Yu Jia Ke
- School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Prasham Dave
- School of Medicine, Queen’s University, Kingston, ON, Canada
- Division of Cardiology, Kingston Health Sciences Network, Kingston, ON, Canada
| | - Bryce Alexander
- School of Medicine, Queen’s University, Kingston, ON, Canada
- Division of Cardiology, Kingston Health Sciences Network, Kingston, ON, Canada
| | - Adham El Sherbini
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Joseph Abunassar
- School of Medicine, Queen’s University, Kingston, ON, Canada
- Division of Cardiology, Kingston Health Sciences Network, Kingston, ON, Canada
| | - Wael Abuzeid
- School of Medicine, Queen’s University, Kingston, ON, Canada
- Division of Cardiology, Kingston Health Sciences Network, Kingston, ON, Canada
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Kisohara M, Kitera N, Itoh T, Murai K, Hiwatashi A, Kawai T. Identification of a small thrombus in the left ventricle identified on iodine maps derived from dual-source photon-counting detector CT. Radiol Case Rep 2024; 19:1404-1408. [PMID: 38268739 PMCID: PMC10803786 DOI: 10.1016/j.radcr.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/06/2024] [Indexed: 01/26/2024] Open
Abstract
Transthoracic echocardiography is the main imaging modality to diagnose left ventricular thrombus (LVT), but its efficacy in certain cases is suboptimal. We report a patient in whom an LVT, initially unidentified by transthoracic echocardiography, was successfully diagnosed with iodine maps derived from dual-source photon-counting detector CT (DS-PCD-CT). The 64-year-old male was admitted to our institution following myocardial infarction. Although TTE failed to detect this small LVT, iodine maps derived from CT angiography (which was conducted to evaluate the coronary artery stenosis) revealed its presence. Iodine maps derived from DS-PCD-CT collecting data with high temporal resolution are beneficial to diagnose LVTs.
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Affiliation(s)
- Masaya Kisohara
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nobuo Kitera
- Central Radiology Division, Nagoya City University Hospital, Nagoya, Japan
| | - Toshihide Itoh
- CT-Research and Collaboration, Siemens Healthineers, Tokyo, Japan
| | - Kazuma Murai
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akio Hiwatashi
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tatsuya Kawai
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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3
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Lopez MD, Vogler J, Aboud A, Heeger CH, Tilz RR. Surgical ventricular reconstruction and intraoperative cryoablation in a patient with drug-refractory ventricular tachycardia and left ventricular thrombus: a case report. Eur Heart J Case Rep 2024; 8:ytae113. [PMID: 38487587 PMCID: PMC10939119 DOI: 10.1093/ehjcr/ytae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Abstract
Background Despite modern techniques for ablation of ventricular tachycardia (VT), the procedure faces challenges such as deep intramural substrates or inaccessibility of the pericardial space. We aim to present a case of successful surgical treatment of a patient with drug-refractory VT, an apical aneurysm, large left ventricular (LV) thrombus, and recurrent implantable cardioverter defibrillator (ICD) shocks following failed epicardial catheter ablation. Case summary A 67-year-old male with a history of ischaemic cardiomyopathy was brought to the emergency room after a syncope because of VT. The VT was terminated by an external cardioversion prior to admission. The ICD interrogation showed an episode of sustained monomorphic VT with eight appropriate but mostly ineffective ICD shocks. An echocardiogram revealed an apical aneurysm with a thrombus. Anticoagulation and antiarrhythmic drug therapy were initiated. Days later, the patient suffered recurrent episodes of sustained VTs, refractory to pharmacological therapy, and epicardial ablation; therefore, following aneurysmectomy and thrombus removal, a reconstruction of the LV and surgical endocardial cryoablation were performed. In addition, ICD extraction was done due to recurrent bacteraemia with Staphylococcus aureus. A subcutaneous ICD was later implanted. After surgery, the patient remained free of any VT episodes during 44 months of follow-up. Conclusion Combined surgical ventricular reconstruction and intraoperative cryoablation may be considered as an alternative, highly effective therapy in patients with drug-refractory VTs in the setting of a LV thrombus.
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Affiliation(s)
- Maryuri Delgado Lopez
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Ratzeburger Allee 160, Lübeck 23538, Germany
| | - Julia Vogler
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Ratzeburger Allee 160, Lübeck 23538, Germany
| | - Anas Aboud
- Department of Cardiac and Thoracic Vascular Surgery, University of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Christian-Hendrik Heeger
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Ratzeburger Allee 160, Lübeck 23538, Germany
| | - Roland Richard Tilz
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Ratzeburger Allee 160, Lübeck 23538, Germany
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Clottes P, Bochaton T, Mechtouff L, Derex L, Cho TH, Fontaine J, Rascle L, Berthezène Y, Amaz C, Thibault H, Bergerot C, Nighoghossian N, Ong E. Safety and efficacy of reperfusion therapies in acute ischemic stroke related to left ventricular thrombus: A retrospective cohort study. Rev Neurol (Paris) 2024:S0035-3787(24)00417-X. [PMID: 38431497 DOI: 10.1016/j.neurol.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 12/04/2023] [Accepted: 12/17/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Left ventricular thrombus (LVT) is a source of cardiogenic embolic stroke. Conflicting data exist in the literature regarding the utilization of intravenous thrombolysis (IVT) at the acute phase of stroke in presence of LVT. We sought to assess the efficacy and safety of reperfusion therapies (IVT and/or thrombectomy) in patients with LVT. METHODS We retrospectively analyzed patients with acute ischemic stroke and proven LVT and divided them in two groups: an intervention group with patients treated by reperfusion therapies and a control group with untreated patients. RESULTS Between 2009 and 2021, 3890 patients were treated by reperfusion therapies in the Lyon stroke center, 33 of whom (0.9%) had LVT. We identified 27 control patients. There were more embolic recurrences at six months in the intervention group than in the control group (nine recurrences versus three, P=0.03, OR=13.56, 95% CI [1.5;195]). Only two early embolic recurrences (< 24h) occurred, both in the IVT group. There was a 4.8-fold decrease in the median NIHSS score between baseline and 24h follow-up in the intervention group (P<0.0001), and the two groups exhibited similar six-month mortality. At stroke onset, cardiopathy was known in 70% of patients, while LVT was known in 30%. CONCLUSION Acute reperfusion therapies seem to be effective in the context of stroke in patients with LVT. However, further studies are needed to support the hypothesis that stroke recurrence might be related to the use of IVT.
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Affiliation(s)
- P Clottes
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France.
| | - T Bochaton
- Service d'urgences cardiologiques et de soins intensifs de cardiologie, hôpital Louis-Pradel, 59, boulevard Pinel, 69500 Bron, France
| | - L Mechtouff
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - L Derex
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - T-H Cho
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - J Fontaine
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - L Rascle
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - Y Berthezène
- Service d'imagerie médicale, 59, boulevard Pinel, 69500 Bron, France
| | - C Amaz
- Centre d'investigations cliniques, hôpital Louis-Pradel, 59, boulevard Pinel, 69500 Bron, France
| | - H Thibault
- Service des explorations fonctionnelles cardiovasculaires, hôpital Louis-Pradel, 59, boulevard Pinel, 69500 Bron, France
| | - C Bergerot
- Service des explorations fonctionnelles cardiovasculaires, hôpital Louis-Pradel, 59, boulevard Pinel, 69500 Bron, France
| | - N Nighoghossian
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - E Ong
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
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Song Y, Li H, Zhang X, Wang L, Xu HY, Lu ZC, Wang XG, Liu B. Individualized anti-thrombotic therapy for acute myocardial infarction complicated with left ventricular thrombus: A case report. World J Clin Cases 2024; 12:835-841. [PMID: 38322693 PMCID: PMC10841139 DOI: 10.12998/wjcc.v12.i4.835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Presently, there is no established standard anti-blood clot therapy for patients facing acute myocardial infarction (AMI) complicated by left ventricular thrombus (LVT). While vitamin K antagonists are the preferred choice for oral blood thinning, determining the best course of blood-thinning medication remains challenging. It is unclear if non-vitamin K antagonist oral blood thinners have different effectiveness in treating LVT. This study significantly contributes to the medical community. CASE SUMMARY The blood-thinning treatment of a patient with AMI and LVT was analyzed. Triple blood-thinning therapy included daily enteric-coated aspirin tablets at 0.1 g, daily clopidogrel hydrogen sulfate at 75 mg, and dabigatran etexilate at 110 mg twice daily. After 15 d, the patient's LVT did not decrease but instead increased. Clinical pharmacists comprehensively analyzed the cases from the perspective of the patient's disease status and drug interaction. The drug regimen was reformulated for the patient, replacing dabigatran etexilate with warfarin, and was administered for six months. The clinical pharmacist provided the patient with professional and standardized pharmaceutical services. The patient's condition was discharged after meeting the international normalized ratio value (2-3) criteria. The patient fully complied with the follow-up, and the time in the therapeutic range was 78.57%, with no serious adverse effects during pharmaceutical monitoring. CONCLUSION Warfarin proves to be an effective drug for patients with AMI complicated by LVT, and its blood-thinning course lasts for six months.
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Affiliation(s)
- Yan Song
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Hua Li
- Department of Cardiology, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Xia Zhang
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Lei Wang
- Department of Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Hong-Yan Xu
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Zhi-Chao Lu
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Xiao-Gang Wang
- Department of Imaging, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Bo Liu
- Department of Pulmonary and Critical Care Medicine, Department of Clinical Microbiology, Zibo City Key Laboratory of Respiratory Infection and Clinical Microbiology, Zibo City Engineering Technology Research Center of Etiology Molecular Diagnosis, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
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Shehadeh M, Rahhal A, Shunnar K, Ahmed AO, AlKhalaila O, Abdelghani M, Mahfouz A, Alyafei S, Arabi A. Percutaneous coronary intervention can be safely performed with left ventricular thrombus without increasing stroke risk: A 5-year retrospective review using real-world data. Int J Cardiol 2024; 395:131415. [PMID: 37802297 DOI: 10.1016/j.ijcard.2023.131415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/04/2023] [Accepted: 10/02/2023] [Indexed: 10/08/2023]
Abstract
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.
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Affiliation(s)
- Mohanad Shehadeh
- Cardiology Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Alaa Rahhal
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Khaled Shunnar
- Cardiology Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | - Ashraf Omer Ahmed
- Internal Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Osama AlKhalaila
- Cardiology Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Abdelghani
- Cardiology Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Mahfouz
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Sumaya Alyafei
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdulrahman Arabi
- Cardiology Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Matsui K, Kitamura T, Torii S, Mishima T, Shikata F, Fukuzumi M, Fujioka S, Araki H, Horikoshi R, Tamura Y, Mori H, Miyaji K. Recurrent left ventricular thrombus due to essential thrombocythemia complicated by COVID-19. J Cardiol Cases 2024; 29:15-18. [PMID: 38188321 PMCID: PMC10770075 DOI: 10.1016/j.jccase.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/18/2023] [Accepted: 09/05/2023] [Indexed: 01/09/2024] Open
Abstract
Essential thrombocythemia is a risk factor for thrombosis and hemorrhage. During the perioperative period of cardiac surgery, the risk of thrombosis and hemorrhage increases. Coronavirus disease 2019 (COVID-19) is also associated with thrombosis. We present the case of a 69-year-old man with essential thrombocythemia complicated by COVID-19 who developed a left ventricular thrombus. We performed thrombectomy, but the patient developed recurrent left ventricular thrombus 8 days after surgery. Emergency redo thrombectomy was performed followed by aggressive blood-thinning therapy. The postoperative course was complicated by cardiac tamponade requiring surgical drainage 8 days after the second surgery. The patient was discharged home 25 days after the second operation without any complications. Learning objective Left ventricular thrombus is a rare but fatal complication associated with essential thrombocythemia. COVID-19 has also been reported to cause coagulopathy. This case suggested that after surgery for left ventricular thrombus complicated by multiple risk factors including essential thrombocythemia and COVID-19, aggressive blood-thinning therapy with combination of anticoagulation, antiplatelet, and metabolic antagonist may help prevent recurrent thrombosis.
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Affiliation(s)
- Kenta Matsui
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tadashi Kitamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shinzo Torii
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Toshiaki Mishima
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Fumiaki Shikata
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masaomi Fukuzumi
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shunichiro Fujioka
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Haruna Araki
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Rihito Horikoshi
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yoshimi Tamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hisaya Mori
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
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He F, Jiao Y, Jiang L. Case report: hunting the hidden: surgical treatment of chronic silent thrombus in the left ventricle in a young alcoholic patient with myocardial bridging. J Cardiothorac Surg 2023; 18:308. [PMID: 37946252 PMCID: PMC10637006 DOI: 10.1186/s13019-023-02414-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND A silent left ventricular thrombus is dangerous. The current standard anticoagulation therapy was ineffective in our case or similar, and the outcome was poor. CASE PRESENTATION A 33-year-old man with a silent left ventricular thrombus was detected incidentally by transthoracic echocardiography. After admission, anti-coagulation with low-molecular-weight heparin therapy was carried out. The CAG revealed 70% systolic stenosis in the middle of the right coronary artery along with myocardial bridging. Unfortunately, an acute left temporal embolism emerged 5 days later, then the patient was transferred to the neurology department for further treatment. One month later, the patient underwent left ventricular thrombectomy, ventricular aneurysm resection, and coronary artery bypass grafting (CABG) and was discharged uneventfully after surgery. CONCLUSIONS Surgical treatment should be a priority for patients with giant or hypermobile left ventricular thrombus or recurrent systemic emboli.
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Affiliation(s)
- Fengpu He
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 67 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Yiping Jiao
- Psychological Teaching and Research Department, Non-commissioned Officer Academy of PAP, Hangzhou, China
| | - Lijun Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 67 Qingchun Road, Hangzhou, 310003, Zhejiang, China.
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9
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Mitsuishi A, Miura Y, Furukawa A, Yoshida K, Fukunaga Y. Surgical removal of multiple left ventricular thrombi with video-assisted cardioscopy: a case report. Eur Heart J Case Rep 2023; 7:ytad519. [PMID: 37942353 PMCID: PMC10629687 DOI: 10.1093/ehjcr/ytad519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/29/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
Background Left ventricular (LV) thrombus is a lethal complication of coronary artery disease that can lead to embolization and sudden death. There is no clear consensus on the optimal treatment for LV thrombi. There is a paucity of case series about surgical excision of LV thrombus in patients with coronary vessel disease. For that, there is insufficient evidence to support surgical excision of LV thrombus and recommend the optimal timing of this procedure. Case summary We report a case of a 52-year-old man with a history of percutaneous catheter intervention for mid-right coronary artery lesion 3 years ago. He presented with two-vessel coronary artery disease with three LV thrombi. The thrombi were mobile and protuberant. We performed coronary artery bypass grafting in both vessels and LV thrombectomy with video-assisted cardioscopy. Discussion Mobile or protuberant thrombus is the most important risk factor for embolization of LV thrombus. On the other hand, LV thrombus size rarely appears in studies as a risk factor for embolization, and when it does, it is a lesser risk factor. There are no case reports describing simultaneous formation of three LV thrombi after myocardial infarction, and it is not known if the risk of embolism is high in such cases. Our patient had very fragile thrombi, and thrombectomy was performed along with coronary artery bypass grafting due to the high risk of embolism.
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Affiliation(s)
- Atsuyuki Mitsuishi
- Department of Cardiovascular Surgery, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-shi, Kochi Prefecture 783-8505, Japan
| | - Yujiro Miura
- Department of Cardiovascular Surgery, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-shi, Kochi Prefecture 783-8505, Japan
| | - Atsuko Furukawa
- Department of Cardiology, Hosogi Hospital, 35, Daizenjicho, Kochi-shi, Kochi Prefecture 780-8535, Japan
| | - Keisuke Yoshida
- Department of Cardiovascular Surgery, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-shi, Kochi Prefecture 783-8505, Japan
| | - Yukiko Fukunaga
- Department of Surgery, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-shi, Kochi Prefecture 783-8505, Japan
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10
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Lorente-Ros Á, Lorente-Ros M, Alonso-Salinas GL, Monteagudo Ruiz JM, Fernández Golfín C, Zamorano Gómez JL. Dataset for the study of the effect of anticoagulation in the incidence of stroke and other outcomes in patients with left ventricular thrombus. Data Brief 2023; 50:109469. [PMID: 37588614 PMCID: PMC10425660 DOI: 10.1016/j.dib.2023.109469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/18/2023] Open
Abstract
The optimal duration of anticoagulation in patients with left ventricular thrombus (LVT) is unknown. The data package herein presented contains the information used to assess the effect of duration of anticoagulation in the incidence of stroke in patients with left ventricular thrombus (LVT) in a tertiary hospital. In order to collect the required data, all transthoracic echocardiography studies at our institution from January 1st 2014 to December 31st 2021 with LVT were retrieved using dedicated software (Phillips Intellispace Cardiovascular; Koninklijke Phillips N.V., 2004-2020). Second, a dataset was designed ad hoc for this study in which the recruited data for the predefined objectives were obtained from electronic medical records. These data included clinical and demographic information including treatment choices (vitamin K antagonists [VKA] versus direct oral anticoagulants [DOAC]), duration of treatment, reason for interruption of treatment, occurrence of stroke, acute myocardial infarction, bleeding events, thrombus resolution, recurrence, and death. Retrieved data were stored in an excel sheet for analysis using the statistical package STATA (StataCorp v. 15.0, College station, TX). This methodology allows the reuse of these data for further analysis, in the context of the present study and also for future recruitment of additional patients from other institutions to increase statistical power.
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Affiliation(s)
- Álvaro Lorente-Ros
- Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
- Universidad Alcalá, Alcalá de Henares, Spain
- Cardiology Department, University Hospital Puerta de Hierro Majadahonda, Spain
| | - Marta Lorente-Ros
- Mount Sinai Morningside Hospital, The Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | | | | | - José L. Zamorano Gómez
- Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
- Universidad Alcalá, Alcalá de Henares, Spain
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11
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Zhang Q, Zhang Z, Zheng H, Wang C, Yu M, Si D, Zhang W. Clinical profile and prognosis of elderly patients with left ventricular thrombus after anticoagulation. Thromb J 2023; 21:75. [PMID: 37430265 PMCID: PMC10332057 DOI: 10.1186/s12959-023-00520-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/01/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Contemporary data regarding the clinical characteristics and prognosis of left ventricular thrombus (LVT) in older adults (aged ≥ 65 years old) are lacking. In this study, we characterized elderly patients with LVT (aged ≥ 65 years old) and investigated the long-term prognosis in this highly vulnerable patient population. METHODS This single-center, retrospective study was conducted from January 2017 to December 2022. Patients with a reported LVT were assessed primarily by transthoracic echocardiography (TEE) and classified into two groups: elderly LVT groups and younger LVT groups. All patients were treated with anticoagulant treatment. Major adverse cardiovascular event (MACE) was defined as the composite of all-cause mortality, systemic embolism, and rehospitalization for cardiovascular events. Survival analyses were performed with the Kaplan-Meier method and Cox proportional-hazard model. RESULTS A total of 315 eligible patients were included. Compared to the younger LVT group (n = 171), the elderly LVT group (n = 144) had a lower proportion of males and lower serum creatinine clearance, as well as a higher level of NT-proBNP, and a higher rate of history of systemic embolism. LVT resolution occurred in 59.7% and 69.0% of patients in the elderly LVT group and younger LVT group, respectively, with no significant difference (adjusted HR, 0.97; 95% CI, 0.74-1.28; P = 0.836). Yet, elderly patients with LVT, had higher prevalence rates of MACE (adjusted HR, 1.52; 95% CI, 1.10-2.11; P = 0.012), systemic embolism (adjusted HR, 2.81; 95% CI, 1.20-6.59; P = 0.017) and all-cause mortality (adjusted HR, 2.20; 95% CI, 1.29-3.74; P = 0.004) compared with younger patients with LVT. After adjusting for mortality in the Fine-Gray model, similar results were observed. Additionally, patients treated with different anticoagulation therapies (DOACs vs. warfarin) achieved a similar improvement in prognosis (P > 0.05) or LVT resolution (P > 0.05) in elderly patients with LVT. CONCLUSIONS Our results found that elderly patients experiencing LVT have a poor prognosis compared with the younger ones. Clinical prognosis in elderly patients did not significantly differ with the type of anticoagulant used. With aging societies worldwide, further evidence of antithrombotic therapy in elderly individuals with LVT is necessary.
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Affiliation(s)
- Qian Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China
| | - Zhongfan Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China
| | - Haikuo Zheng
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China
| | - Chengbing Wang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Changchun, Jilin, China
| | - Miao Yu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China
| | - Daoyuan Si
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China.
| | - Wenqi Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China.
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12
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Wang YD, Lin JF, Huang XY, Han XD. Successful treatment of veno-arterial extracorporeal membrane oxygenation complicated with left ventricular thrombus by intravenous thrombolysis: A case report. World J Clin Cases 2023; 11:3323-3329. [PMID: 37274033 PMCID: PMC10237126 DOI: 10.12998/wjcc.v11.i14.3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Left ventricular thrombus is a rare condition, for which appropriate treatments are not extensively studied. Although it can be treated by thrombectomy, such surgery can be difficult and risky, and not every patient can tolerate the surgery.
CASE SUMMARY We report a case of a middle-aged man receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for acute myocardial infarction who developed left ventricular thrombus despite systemic anticoagulation. After systemic thrombolysis with urokinase, the left ventricular thrombus disappeared, ECMO was successfully withdrawn 9 days later, and the patient recovered and was discharged from hospital.
CONCLUSION Systemic thrombolysis is a treatment option for left ventricular thrombus in addition to anticoagulation and thrombectomy.
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Affiliation(s)
- Ya-Dong Wang
- Intensive Care Medicine, Nantong Third People's Hospital, Nantong 226000, Jiangsu Province, China
| | - Jin-Feng Lin
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong 226000, Jiangsu Province, China
| | - Xiao-Ying Huang
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong 226000, Jiangsu Province, China
| | - Xu-Dong Han
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong 226000, Jiangsu Province, China
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13
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Yang Q, Quan X, Wang C, Yu L, Yang Y, Zhu J, Liang Y. A prediction model for left ventricular thrombus persistence/recurrence: based on a prospective study and a retrospective study. Thromb J 2023; 21:50. [PMID: 37122028 PMCID: PMC10150477 DOI: 10.1186/s12959-023-00488-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/07/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND It remains unknown whether anticoagulation for persistent left ventricular (LV) thrombus should be continued indefinitely. Identifying patients with a high risk of thrombus unresolved may be helpful to determine the optimum anticoagulation duration. This study aimed to develop a prediction model to forecast thrombus persistence or recurrence in patients with LV thrombus. METHODS We enrolled patients prospectively from 2020 to 2022 and retrospectively from 2013 to 2019 at the National Center of Cardiovascular Diseases of China. The two cohorts were then combined to derive predictive models of thrombus persistence/recurrence. The primary study comprised patients who received systemic oral anticoagulants and had imaging records available at the end of a 3-month follow-up period. The Lasso regression algorithm and the logistic regression were performed to select independent predictors. The calibration curve was generated and a nomogram risk prediction model was applied as a risk stratification tool. RESULTS A total of 172 (64 in the prospective cohort and 108 in the retrospective cohort) patients were included, with 124 patients in a training set and 48 patients in a validation set. Six predictors were incorporated into the multivariate logistic regression prediction model. The area under the receiving operating characteristic was 0.852 in the training set and 0.631 in the validation set. Patients with protuberant thrombus and higher baseline D-dimer levels had a reduced risk of persistence/recurrence (OR 0.17, 95% CI 0.03-0.69, P = 0.025; OR 0.67, 95% CI 0.43-0.91, P = 0.030, separately), whereas thicker thrombus was linked to an increased rate of persistent thrombus (OR 1.11, 95% CI 1.05-1.20, P = 0.002). Additionally, patients with diverse diagnoses or receiving different antiplatelet treatments had different rates of LV thrombus persistence/recurrence at 3 months. CONCLUSIONS This prediction model provides tools to forecast the occurrence of persistent/recurrent thrombus and allows the identification of characteristics associated with unresolved thrombus. To validate the model and determine the duration of anticoagulation in patients with persistent thrombus, prospective randomized trials are necessary.
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Affiliation(s)
- Qing Yang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Xin Quan
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Department of Echocardiographic, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Chuangshi Wang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Room 101-106, Block A, Shilong West Road, Mentougou District, Beijing, China
| | - Litian Yu
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yanmin Yang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Jun Zhu
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yan Liang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
- Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
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14
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Kim SE, Lee CJ, Oh J, Kang SM. Factors influencing left ventricular thrombus resolution and its significance on clinical outcomes. ESC Heart Fail 2023; 10:1987-1995. [PMID: 37009745 DOI: 10.1002/ehf2.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/09/2023] [Accepted: 03/19/2023] [Indexed: 04/04/2023] Open
Abstract
AIMS A left ventricular thrombus (LVT) is not uncommon in patients with impaired LV systolic function. However, the treatment strategy for LVT has not yet been fully established. We aimed to identify the factors influencing LVT resolution and the significance of LVT resolution on clinical outcomes. METHODS We retrospectively investigated patients diagnosed with LVT with left ventricular ejection fraction (LVEF) < 50% on transthoracic echocardiography from January 2010 to July 2021 in a single tertiary centre. LVT resolution was monitored through serial follow-up transthoracic echocardiography. The primary clinical outcome was a composite of all-cause death, stroke, transient ischaemic attack, and arterial thromboembolic events. LVT recurrence was also evaluated in patients with LVT resolution. RESULTS There were 212 patients diagnosed with LVT (mean age, 60.5 ± 14.0 years; male, 82.5%). The mean LVEF was 33.1 ± 10.9%, and 71.7% of patients were diagnosed with ischaemic cardiomyopathy. Most patients were treated with vitamin K antagonists (86.7%), and 28 patients (13.2%) were treated with direct oral anticoagulants or low molecular weight heparin. LVT resolution was observed in 179 patients (84.4%). LVEF improvement failure within 6 months was a significant factor hindering LVT resolution (hazard ratio, HR: 0.52, 95% confidence interval, CI: 0.31-0.85, P = 0.010). During a median 4.0 years of follow-up (interquartile range, IQR: 1.9 to 7.3 years), 32 patients (15.1%) experienced primary outcomes (18 all-cause deaths, 15 strokes, and 3 arterial thromboembolisms) and 20 patients (11.2%) experienced LVT recurrence after LVT resolution. LVT resolution was independently associated with a lower risk for primary outcomes (HR: 0.45, 95% CI: 0.21-0.98, P = 0.045). In the patients with resolved LVT, discontinuation or duration of anticoagulation after resolution were not significant predictors for LVT recurrence, but LVEF improvement failure at LVT resolution was associated with a significantly higher risk of LVT recurrence (HR: 3.10, 95% CI: 1.23-7.78, P = 0.016). CONCLUSIONS This study suggests that LVT resolution is an important predictor for favourable clinical outcomes. LVEF improvement failure interfered with LVT resolution and appeared to be a crucial factor for LVT recurrence. After LVT resolution, continuation of anticoagulation did not seem to impact LVT recurrence and the prognosis.
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Affiliation(s)
- Se-Eun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chan Joo Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaewon Oh
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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15
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Meno MK, Chen DX, Pattock AM, Huang GS. Massive Left Ventricular Thrombus After ST-Segment Elevation Myocardial Infarction in a Young Man With Factor V Leiden. CASE (Phila) 2023; 7:142-146. [PMID: 37123632 PMCID: PMC10147543 DOI: 10.1016/j.case.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
STEMI caused by obstructive CAD is uncommon in young adults. Factor V Leiden and antipsychotic medication use may increase the risk for ACS. LV thrombus is a common complication of acute anterior STEMI. TTE is the most common imaging modality used in diagnosing LV thrombus. Anticoagulation therapy for LV thrombus should be individually tailored.
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Affiliation(s)
- Michael K. Meno
- University of Washington, Seattle, Washington
- Correspondence: Michael K. Meno, MD, University of Washington, 1959 NE Pacific Street, Box 356421, Seattle, WA 98195-6421.
| | | | | | - Gary S. Huang
- Cardiovascular Medical Group of San Francisco, San Francisco, California
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16
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Liori S, Samiotis E, Birba D, Katsimbri P, Mademli M, Bakola E, Tsivgoulis G, Quris E, Bonios M, Kalabaliki M, Farmakis D, Parissis J, Frogoudaki A. Churg-Strauss syndrome-associated heart failure and left ventricular thrombosis. ESC Heart Fail 2023; 10:2107-2112. [PMID: 36965162 DOI: 10.1002/ehf2.14244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 03/27/2023] Open
Abstract
We present a case of a 47-year-old woman with a history of asthma and mononeuritis who presented with shortness of breath and fatigue. Heart failure was diagnosed and echocardiography revealed large floating thrombi attached to the left ventricular walls. Cardiac magnetic resonance imaging showed evidence of myocarditis and angiitis. Blood count revealed eosinophilia. She was diagnosed with eosinophilic granulomatosis with polyangiitis or Churg-Strauss syndrome (CSS) according to recently updated criteria. Medical management with specific aetiology (anticoagulation or immunosuppression) and heart failure treatment resulted in clinical improvement. We further discuss the diagnostic approach of CSS with cardiovascular complications and therapeutic management.
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Affiliation(s)
- Sotiria Liori
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Samiotis
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dionysia Birba
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Pelagia Katsimbri
- Rheumatology and Clinical Immunology Unit, Fourth Department of Internal Medicine, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Mademli
- Second Department of Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Bakola
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Estela Quris
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Bonios
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Maria Kalabaliki
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - John Parissis
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandra Frogoudaki
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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17
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Yang Q, Quan X, Zhang Y, Feng G, Zhang T, Wang C, Yu D, Yu L, Yang Y, Zhu J, Liang Y. An exploratory study of effectiveness and safety of rivaroxaban in patients with left ventricular thrombus (R-DISSOLVE). J Thromb Thrombolysis 2023; 55:649-659. [PMID: 36940069 PMCID: PMC10026792 DOI: 10.1007/s11239-023-02790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 03/21/2023]
Abstract
Evidence on the treatment for left ventricular (LV) thrombus is limited and mainly derives from retrospective studies. The aim of R-DISSOLVE was to explore the effectiveness and safety of rivaroxaban in patients with LV thrombus. R-DISSOLVE was a prospective, interventional, single-arm study, conducted from Oct 2020 to June 2022 at Fuwai Hospital, China. Patients with a history of LV thrombus < 3 months and with systemic anticoagulation therapy < 1 month were included. The thrombus was quantitatively confirmed by contrast-enhanced echocardiography (CE) at baseline and follow-up visits. Eligible patients were assigned to rivaroxaban (20 mg once daily or 15 mg if creatinine clearance was between 30 and 49 mL/min) and its concentration was determined by detecting anti-Xa activity. The primary efficacy outcome was the rate of LV thrombus resolution at 12 weeks. The main safety outcome was the composite of ISTH major and clinically relevant non-major bleeding. A total of 64 patients with complete CE results were analyzed for efficacy outcomes. The mean LV ejection fraction was 25.4 ± 9.0%. The dose-response curve of rivaroxaban was satisfactory based on the peak and trough plasma levels and all concentrations were in the recommended treatment range according to NOAC guidelines. The incidence rate of thrombus resolution at 6 weeks was 66.1% (41/62, 95% CI 53.0-77.7%), and of thrombus resolution or reduction was 95.2% (59/62, 95% CI 86.5-99.0%). At 12 weeks, the thrombus resolution rate was 78.1% (50/64, 95% CI 66.0-87.5%) while the rate of thrombus resolution or reduction was 95.3% (61/64, 95% CI 86.9-99.0%). The main safety outcome occurred in 4 of 75 patients (5.3%) (2 ISTH major bleeding and 2 clinically relevant non-major bleeding). In patients with LV thrombus, we reported a high thrombus resolution rate with acceptable safety by rivaroxaban, which could be a potential option for further LV thrombus treatment.Trial registration This study was registered at ClinicalTrials.gov as NCT04970381.
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Affiliation(s)
- Qing Yang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Xin Quan
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Department of Echocardiographic, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yang Zhang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Department of Laboratory Medicine, National Center for Cardiovascular Diseases and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Guangxun Feng
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Tao Zhang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Chuangshi Wang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Room 101-106, Block A, Shilong West Road, Mentougou District, Beijing, China
| | - Dongze Yu
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Department of Laboratory Medicine, National Center for Cardiovascular Diseases and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Litian Yu
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yanmin Yang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Jun Zhu
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yan Liang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
- Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
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18
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Suzuki K, Sakamoto SI, Hiromoto A, Motoji Y, Amitani R, Yamaguchi T, Ishii Y. Case of left ventricular thrombus managed with thrombectomy with left ventricular reconstruction in a patient who had coronavirus disease 2019 infection. J Cardiothorac Surg 2023; 18:8. [PMID: 36611152 PMCID: PMC9823256 DOI: 10.1186/s13019-023-02108-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Kenji Suzuki
- grid.459842.60000 0004 0406 9101Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-Ku, Kawasaki, Kanagawa 211-8533 Japan
| | - Shun-Ichiro Sakamoto
- grid.459842.60000 0004 0406 9101Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-Ku, Kawasaki, Kanagawa 211-8533 Japan
| | - Atsushi Hiromoto
- grid.459842.60000 0004 0406 9101Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-Ku, Kawasaki, Kanagawa 211-8533 Japan
| | - Yusuke Motoji
- grid.459842.60000 0004 0406 9101Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-Ku, Kawasaki, Kanagawa 211-8533 Japan
| | - Ryosuke Amitani
- grid.459842.60000 0004 0406 9101Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-Ku, Kawasaki, Kanagawa 211-8533 Japan
| | - Takako Yamaguchi
- grid.459842.60000 0004 0406 9101Department of Nursing, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimach, Nakahara-ku, Kawasaki, Kanagawa 211-8533 Japan
| | - Yosuke Ishii
- grid.410821.e0000 0001 2173 8328Department of Cardiovascular Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602 Japan
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Kitmeridou S, Tsiptsios D, Tsalkidis D, Psatha EA, Iliopoulos I, Aggelousis N, Vadikolias K. Intravenous thrombolysis for acute ischemic stroke associated with known left ventricular thrombus: safe or not? Neurol Res Pract 2022; 4:61. [PMID: 36550521 PMCID: PMC9773473 DOI: 10.1186/s42466-022-00227-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Safety and efficacy data on intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) in case of known left ventricular thrombus (LVT) are lacking. We present the case of a 35-year-old male with disabling AIS and known LVT that was treated successfully with intravenous alteplase. Apart from neurological improvement, post-procedural full thrombus lysis was also evident. Even though performing IVT in similar instances constitutes a difficult decision for physicians, it may be reasonable in the context of acute disabling stroke.
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Affiliation(s)
- Sofia Kitmeridou
- Neurology Department, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Tsiptsios
- Neurology Department, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Dimos Tsalkidis
- Neurology Department, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evlampia A Psatha
- Neurology Department, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ioannis Iliopoulos
- Neurology Department, Democritus University of Thrace, Alexandroupolis, Greece
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, Komotini, Greece
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20
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Di Odoardo LAF, Bianco M, Gil IJN, Motolese IG, Chinaglia A, Vicenzi M, Carugo S, Stefanini GG, Cerrato E. Left Ventricular Thrombus Management After Acute Myocardial Infarction in Clinical Practice: Results from LEVITATION Survey and Narrative Review. Cardiovasc Drugs Ther 2022:10.1007/s10557-022-07417-w. [PMID: 36538031 DOI: 10.1007/s10557-022-07417-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Left ventricular thrombus (LVT) after ST-elevation myocardial infarction still presents diagnostic and therapeutic challenges. The LEVITATION survey was designed to take a picture of LVT management in current clinical practice. METHODS The survey covered diagnostic, therapeutic, and prophylactic issues and was completed by 104 European cardiac centers. Most of them (59%) were university or tertiary centers. RESULTS The survey showed anterior apical a-/dyskinesia, large MI, spontaneous echo-contrast, late presentation with delayed PCI, and TIMI flow 0-1 as the most important perceived risk factors for LVT formation. Serial ultrasound imaging is the most used tool to diagnose LVT (88% of the centers), with contrast-enhanced ultrasound and cardiac MR performed in case of poor apex visualization or spontaneous echo-contrast. One third (34%) of the centers uses prophylactic anticoagulation to prevent LVT formation. In the presence of LVT, low molecular weight heparin is the most used in-hospital therapy. At discharge, vitamin K antagonist and direct oral anticoagulants are used in 67 and 32% of the cases, respectively. Triple antithrombotic therapy with aspirin plus clopidogrel and VKA is the most used strategy at discharge (55%), whereas a single antiplatelet therapy is preferred only in the case of moderate-to-high risk of bleeding. To assess LVT total regression, half of the centers use contrast-enhanced ultrasound and/or cardiac-MR. The duration of anticoagulation is usually 3-6 months (55%), with long-term prolongation in case of LVT persistence or recurrence. CONCLUSION The survey has depicted for the first time the current real-world management of this neglected topic and has highlighted several grey zones that are still present and not supported by evidence.
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Affiliation(s)
- Luca A F Di Odoardo
- Cardiology Unit, Cardiotoracovascular Department, Legnano Hospital, Legnano, Milan, Italy.
| | - Matteo Bianco
- Cardiology Division, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy.
| | - Iván J Núñez Gil
- Cardiovascular Institute, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Italo G Motolese
- Cardiology Division, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Alessandra Chinaglia
- Cardiology Division, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Marco Vicenzi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Cardiovascular Disease Unit, Department of Internal Medicine, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Carugo
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Cardiovascular Disease Unit, Department of Internal Medicine, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital and Infermi Hospital, Orbassano and Rivoli, Turin, Italy
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21
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Liang J, Wang Z, Zhou Y, Shen H, Chai M, Ma X, Han H, Shao Q, Li Q. Efficacy and Safety of Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus After Acute Anterior Myocardial Infarction in Patients Who Underwent Percutaneous Coronary Intervention. Curr Vasc Pharmacol 2022; 20:517-526. [PMID: 36200193 DOI: 10.2174/1570161120666221003104821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
AIMS To explore treatment with Direct Oral Anticoagulants (DOACs) in left ventricular thrombus (LVT) after ST-segment elevation myocardial infarction (STEMI) in patients who underwent percutaneous coronary intervention (PCI). BACKGROUND Contemporary data regarding using DOACs for LVT after STEMI patients who underwent PCI is limited. OBJECTIVES To investigate the efficacy and safety of DOACs on the treatment of LVT post STEMI and PCI. METHODS This retrospective study enrolled patients with LVT post STEMI and PCI within 1month from onset who received warfarin or DOACs at discharge. The primary endpoint was LVT resolution. Secondary endpoints were major adverse cardiovascular events (MACEs), including death, stroke, systemic embolism (SE), myocardial infarction (MI) and major or minor bleeding. RESULTS A total of 128 consecutive patients were recruited, of which 72 received warfarin and 56 DOACs [48 on rivaroxaban and 8 on dabigatran]. The rate of LVT resolution was higher within 1 month in the DOACs group than warfarin (26.8% vs. 11.1%; p = 0.022) (Kaplan-Meier estimates, p = 0.002). No significant differences were found at 3 months (p = 0.246), 6 months (p = 0.201), 9 months (p = 0.171) and 12 months (p = 0.442). No patients treated with DOACs had major bleeding, while two patients with warfarin had upper gastrointestinal bleeding (0 vs. 2 (2.8%); p = 0.209). No death or SE occurred. No significant differences on secondary endpoints were found in both the groups, including stroke, MI, minor bleeding and all bleeding events. CONCLUSION DOACs appear to be a suitable alternative to warfarin for the management of LVT post STEMI, especially in patients who are intolerant to warfarin.
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Affiliation(s)
- Jing Liang
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Zhijian Wang
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Hua Shen
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Meng Chai
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Xiaoteng Ma
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Hongya Han
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Qiaoyu Shao
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Qiuxuan Li
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
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22
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Huang L, Tan Y, Pan Y. Systematic review of efficacy of direct oral anticoagulants and vitamin K antagonists in left ventricular thrombus. ESC Heart Fail 2022; 9:3519-3532. [PMID: 35894752 PMCID: PMC9715875 DOI: 10.1002/ehf2.14084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS Left ventricular thrombus (LVT) increases the risk of thrombotic events and mortality. Vitamin K antagonists (VKAs) used to treat LVT have several known risks, as a result of which direct oral anticoagulant (DOAC) use has recently increased. We aimed to evaluate the safety and efficacy of DOACs and VKAs in treating LVT. METHODS AND RESULTS We searched PubMed, Embase, Cochrane Library trials, and Web of Science databases for studies published before 19 April 2022, involving DOAC versus VKA treatment for patients with LVT. This meta-analysis comprised 21 studies (total patients, n = 3172; DOAC group, n = 888; VKA group, n = 2284). A statistically significant reduction in bleeding events was observed in patients on DOACs vs. those on VKAs (risk ratio (RR) = 0.73, P = 0.004). Patients on DOACs residing in North American and European regions and those with ischaemic heart disease (IHD) had a significantly lower risk of bleeding events than patients residing in other regions or those with a different LVT aetiology, respectively (RR = 0.78, P = 0.04; RR = 0.38, P = 0.02; and RR = 0.63, P = 0.009). A statistically significant reduction in stroke in patients on DOACs versus VKAs (RR = 0.72, P = 0.03) was observed, and patients on DOACs residing in North America and those with IHD had a significantly lower risk of stroke (RR = 0.73, P = 0.04, and RR = 0.61, P = 0.03, respectively). Compared with VKAs, DOACs are statistically associated with an increase in LVT resolution at 1 month (RR = 1.96, P = 0.008). No statistical between-group difference in all-cause mortality (RR = 0.72, P = 0.05), systemic embolism (RR = 0.87, P = 0.74), stroke or systemic embolism (RR = 0.90, P = 0.50), and LVT resolution at the end of follow-up (RR = 1.06, P = 0.13) was observed. CONCLUSIONS Compared with VKAs, DOACs significantly reduce the risk of bleeding events and stroke in LVT patients, but mortality was similar in both groups. The advantages are apparent not only in patients belonging to the predominantly white residential areas such as North American and European regions but also in patients with LVT due to IHD. DOACs show promising effects in treating LVT compared with VKAs.
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Affiliation(s)
- Lei Huang
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Yuan Tan
- Department of AnesthesiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Yilong Pan
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
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23
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Yamaguchi D, Endo H, Ishikawa K, Nomura R, Oka K, Nakamura H. Large vessel occlusions requiring repeated mechanical thrombectomy caused by silent myocardial infarction in a young adult. J Stroke Cerebrovasc Dis 2022; 31:106761. [PMID: 36095858 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/04/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Silent myocardial ischemia, defined as objective evidence of myocardial ischemia without symptoms, is associated with ischemic stroke. Nevertheless, silent myocardial infarction is a rare cause of ischemic stroke, especially in young adults with no medical history. MATERIALS AND METHODS Herein, we report a young adult patient with acute ischemic stroke treated with repeated mechanical thrombectomy for recurrent large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. RESULTS A 40-year-old man was transferred by ambulance to our hospital because of a generalized seizure. He was diagnosed with cerebral infarction and left middle cerebral artery occlusion. We performed intravenous thrombolysis and mechanical thrombectomy. Recanalization was achieved and his symptoms gradually improved. However, the day after treatment he developed bilateral cerebellar infarction and basilar artery occlusion. We performed a second mechanical thrombectomy and recanalization was achieved. Transthoracic echocardiography revealed a mobile left ventricular thrombus. Although he had no previous chest symptomatic episodes, cardiac examination confirmed myocardial infarction of unknown onset. He was diagnosed with acute ischemic stroke with large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. Anticoagulation therapy reduced the amount of thrombus. At 1-year follow-up, he had not experienced any recurrences or symptoms. CONCLUSIONS Silent myocardial infarction should be considered a cause of ischemic stroke in young adults, even without any vascular risk factors. Recurrent large vessel occlusion may occur in patients with left ventricular thrombus, and repeated mechanical thrombectomy should be considered for treatment.
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Affiliation(s)
- Daishi Yamaguchi
- Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan
| | - Hideki Endo
- Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan.
| | - Kohei Ishikawa
- Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan
| | - Ryota Nomura
- Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan
| | - Koji Oka
- Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan
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24
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Allard L, Bernhard B, Windecker S, Valgimigli M, Gräni C. Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge. Eur Heart J Qual Care Clin Outcomes 2022; 8:496-509. [PMID: 34928322 DOI: 10.1093/ehjqcco/qcab097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 12/29/2022]
Abstract
Although the management of ischaemic heart disease has markedly improved over the last decades, left ventricular thrombus remains a serious finding in patients with myocardial infarction. Routine diagnostic detection of left ventricular thrombus relies mainly on echocardiography; however, cardiac magnetic resonance has emerged as a method with higher diagnostic accuracy, while cardiac computed tomography angiography represents a valuable alternative modality. To reduce the left ventricular thrombus-associated morbidity and mortality, optimal selection of anticoagulation is warranted after balancing the risk of bleeding. In this review, we will discuss contemporary diagnostic modalities to detect left ventricular thrombus in ischaemic heart disease and summarize evidence on risk stratification and therapy. In addition, we propose a novel diagnosis, follow-up imaging, and treatment algorithm. Further, we identify knowledge gaps at different levels to address emerging research questions and to refine the design of future studies aiming to improve the management of patients in this clinical setting.
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Affiliation(s)
- Ludovic Allard
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.,Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale and Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | - Christoph Gräni
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
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25
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Mitropoulou P, Hobson A, Morton G, Anantharam B. ST-elevation myocardial infarction in a young patient with Duchenne's muscular dystrophy: a case report. Eur Heart J Case Rep 2022; 6:ytac184. [PMID: 35582544 PMCID: PMC9109008 DOI: 10.1093/ehjcr/ytac184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/27/2021] [Accepted: 04/28/2022] [Indexed: 11/21/2022]
Abstract
Background Duchenne's muscular dystrophy (DMD) is an X-linked muscular disease which is caused by the absence of dystrophin. This results in the death of muscle cells and cardiomyocytes and consequent substitution by fat and fibrous tissue. The clinical translation of this is muscle weakness and cardiomyopathy. We report on the case of a young patient with dilated cardiomyopathy on a background of DMD who developed ST-elevation myocardial infarction (STEMI). Case summary A 19-year-old male patient with DMD, known dilated cardiomyopathy, and no risk factors for ischaemic heart disease presented with central crushing chest pain. His electrocardiogram revealed anterior ST elevation. His angiogram revealed distally occluded left anterior descending and second diagonal branch with no evidence of underlying coronary artery disease. He was treated with balloon angioplasty. An echocardiogram raised the suspicion of a left ventricular thrombus, and the mechanism of STEMI was felt to be embolism from the left ventricular thrombus on a background of dilated cardiomyopathy in the context of DMD. The patient was treated with anticoagulants (warfarin). On a repeat echocardiogram a few months later, the thrombus had resolved. At 3 years of follow-up, the patient did not present any more embolic events. Discussion To our knowledge, this is the first case of STEMI secondary to thrombotic coronary occlusion that has been described in a patient with DMD. This case highlights an unusual complication of DMD. Based on this case, we discuss the dilemmas in the management and follow-up of this complex patient population.
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Affiliation(s)
- Panagiota Mitropoulou
- Cardiology Department, University Hospital
Southampton NHS Foundation Trust, Southampton, UK,Corresponding author: Tel: +44 7437841478,
| | - Alexander Hobson
- Cardiology Department, Portsmouth Hospitals
University NHS Trust, Portsmouth, UK
| | - Geraint Morton
- Cardiology Department, Portsmouth Hospitals
University NHS Trust, Portsmouth, UK
| | - Brijesh Anantharam
- Cardiology Department, Portsmouth Hospitals
University NHS Trust, Portsmouth, UK
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26
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Del Rio-Pertuz G, Morataya C, Iskandir M, Argueta-Sosa E. Acute Myocardial Infarction Associated With a Mobile Left Ventricular Thrombi. J Investig Med High Impact Case Rep 2022; 10:23247096221078704. [PMID: 35225697 PMCID: PMC8891841 DOI: 10.1177/23247096221078704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The majority of acute coronary syndromes are caused by coronary artery thrombotic occlusions secondary to atherosclerotic plaque erosion or rupture. Coronary embolism is an important yet forgotten underlying cause of acute coronary syndrome. We present a case of a young patient who presented with ST elevation myocardial infarction suspected to be secondary to coronary embolization originating from a left ventricular thrombus.
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Affiliation(s)
- Gaspar Del Rio-Pertuz
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Cristina Morataya
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Marina Iskandir
- Division of Cardiology, Texas Tech Univetsity Health Sciences Center, Lubbock, Texas, USA
| | - Erwin Argueta-Sosa
- Division of Cardiology, Texas Tech Univetsity Health Sciences Center, Lubbock, Texas, USA
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27
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Wang P, Ye X, Yan D, Peng Y, Zhang Z. Incidence and Risk Factors of Left Ventricular Thrombus in Acute ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention: A Meta-Analysis. Med Princ Pract 2022; 31:415-423. [PMID: 35797977 PMCID: PMC9801374 DOI: 10.1159/000525943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/05/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Left ventricular thrombosis (LVT) is a common complication of acute ST-segment elevation myocardial infarction (STEMI). This study attempted to synthesize the available evidence to understand the incidence and risk factors of LVT in acute STEMI patients undergoing primary percutaneous coronary intervention (PCI). METHODS We searched PubMed, Embase, Cochrane Library, and Web of Science for studies published from January 2001 to January 2022. The random-effects and fixed-effects model meta-analysis estimated pooled incidence, mean difference (MD), odds ratio (OR), and 95% confidence interval (CI). The Review Manager 5.4 software was used for meta-analysis performance. RESULTS The results of meta-analysis showed that the incidence of LVT in acute STEMI treated by primary PCI was 4% (95% CI [0.03, 0.05]), and the overall pooled incidence in patients with anterior STEMI was 10.0% (95% CI [0.07, 0.12]). Anterior STEMI (OR = 11.93, 95% CI [6.25, 22.78], p = 0.0003), left anterior descending-related infarct (OR = 6.85, 95% CI [3.70, 12.66], p < 0.00001), left ventricular wall motion abnormalities (OR = 7.53, 95% CI [3.18, 17.82], p < 0.00001), and lower post-PCI LVEF (MD = 13.78, 95% CI [12.15, 15.41], p < 0.00001) were risk factors for post-PCI LVT. CONCLUSION The incidence of LVT after acute STEMI in the PCI era remains high. This study provides a preliminary overview of STEMI patients at risk for post-PCI LVT and will help the design of prospective randomized controlled trials for the management and prevention of LVT.
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Affiliation(s)
- Pei Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
- *Zheng Zhang,
| | - Xudong Ye
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Dongdong Yan
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yu Peng
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, China
- Gansu Key Laboratory of Cardiovascular Disease, Lanzhou, China
| | - Zheng Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, China
- Gansu Key Laboratory of Cardiovascular Disease, Lanzhou, China
- *Zheng Zhang,
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28
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Honan KA, Jogimahanti A, Khair T. An Updated Review of the Efficacy and Safety of Direct Oral Anticoagulants in Treatment of Left Ventricular Thrombus. Am J Med 2022; 135:17-23. [PMID: 34469758 DOI: 10.1016/j.amjmed.2021.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022]
Abstract
Left ventricular (LV) thrombus is a potentially serious complication affecting males and females with ischemic and nonischemic cardiomyopathy-specifically, after acute myocardial infarctions of the anterior left ventricular wall and long-standing tachyarrhythmias, respectively. LV thrombi pose significant risks for systemic embolization and devastating stroke events, while also demanding a treatment carrying inherent risks of its own. It is therefore imperative to have accurate detection of these ventricular thrombi and an appropriate understanding of the risks and benefits regarding management. Anticoagulation using warfarin has long been established as the gold-standard level of care in the current guidelines of the American College of Cardiology but the advent of direct oral anticoagulants (DOACs) prompts a re-examination of the literature. The particular question we seek to answer lies in the efficacy of these drugs and the safety and outcomes when used to treat LV thrombi. Recent case reports, meta-analyses, and most recently, the breakthrough of 2 novel randomized controlled trials have shown DOACs to be a promising treatment for LV thrombus. Contrarily, some retrospective cohort reviews suggest less-than-promising outcomes. This meta-analysis hopes to provide a current, curated review of up-to-date safety and efficacy in the documented tales of DOACs and LV thrombi that has been published since early 2020-by selecting these curated case studies, and analyzing the most recent randomized controlled trials, we hope to engage the reader with clearer illustrations of the key components of both the advocacy and warning of this pharmaceutical intervention.
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Affiliation(s)
- Kevin A Honan
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston.
| | - Arjun Jogimahanti
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston
| | - Tarif Khair
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston
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29
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Barfuss SB, Truong DT, James KE, Inman CJ, Husain SA, Williams RV, Minich LL, Mart CR. Left ventricular thrombus in the multisystem inflammatory syndrome in children associated with COVID-19. Ann Pediatr Cardiol 2022; 15:90-93. [PMID: 35847408 PMCID: PMC9280099 DOI: 10.4103/apc.apc_82_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/07/2021] [Indexed: 11/28/2022] Open
Abstract
A 3-year-old girl presenting with fever, mucocutaneous inflammation, and acute gastrointestinal symptoms met criteria for the multisystem inflammatory syndrome in children associated with COVID-19 (MIS-C). Echocardiography showed severely decreased left ventricular (LV) function with an apical mass. After treatment with intravenous (IV) immunoglobulin, IV steroids, anakinra, milrinone, and systemic anticoagulation, her LV function rapidly improved and the mass became increasingly mobile. Given the risk of systemic embolization, the mass was excised through left ventriculotomy and pathology confirmed a thrombus.
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Affiliation(s)
- Spencer B. Barfuss
- Department of Pediatrics, Division of Cardiology, University of Utah/Primary Children's Hospital, Utah, USA,Address for correspondence: Dr. Spencer B. Barfuss, 81 N. Mario Capecchi Drive, Salt Lake City, Utah, 84113, USA. E-mail:
| | - Dongngan T. Truong
- Department of Pediatrics, Division of Cardiology, University of Utah/Primary Children's Hospital, Utah, USA
| | - Karen E. James
- Department of Pediatrics, Division of Rheumatology, University of Utah/Primary Children's Hospital, Utah, USA
| | - Christi J. Inman
- Department of Pediatrics, Division of Rheumatology, University of Utah/Primary Children's Hospital, Utah, USA
| | - S. Adil Husain
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah/Primary Children's Hospital, Utah, USA
| | - Richard V. Williams
- Department of Pediatrics, Division of Cardiology, University of Utah/Primary Children's Hospital, Utah, USA
| | - L. LuAnn Minich
- Department of Pediatrics, Division of Cardiology, University of Utah/Primary Children's Hospital, Utah, USA
| | - Christopher R. Mart
- Department of Pediatrics, Division of Cardiology, University of Utah/Primary Children's Hospital, Utah, USA
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Mathur P, Fnu A, Mehta JL. How to treat left ventricular thrombi- warfarin or direct oral anti-coagulants? Am Heart J Plus 2022; 13:100075. [PMID: 38560064 PMCID: PMC10978216 DOI: 10.1016/j.ahjo.2021.100075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Pankaj Mathur
- The University of Arkansas for Medical Sciences Central Arkansas Veterans Healthcare System, Little Rock, AR, United States of America
| | - Amisha Fnu
- The University of Arkansas for Medical Sciences Central Arkansas Veterans Healthcare System, Little Rock, AR, United States of America
| | - Jawahar L. Mehta
- The University of Arkansas for Medical Sciences Central Arkansas Veterans Healthcare System, Little Rock, AR, United States of America
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Mathur P, Fnu A, Mehta JL. How to treat left ventricular thrombi - Warfarin or direct oral anti-coagulants? Am Heart J Plus 2022; 13:100078. [PMID: 38560069 PMCID: PMC10978180 DOI: 10.1016/j.ahjo.2021.100078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 04/04/2024]
Affiliation(s)
- Pankaj Mathur
- The University of Arkansas for Medical Sciences Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Amisha Fnu
- The University of Arkansas for Medical Sciences Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Jawahar L. Mehta
- The University of Arkansas for Medical Sciences Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
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Chen M, Liu D, Weidemann F, Lengenfelder BD, Ertl G, Hu K, Frantz S, Nordbeck P. Echocardiographic risk factors of left ventricular thrombus in patients with acute anterior myocardial infarction. ESC Heart Fail 2021; 8:5248-5258. [PMID: 34498435 PMCID: PMC8712797 DOI: 10.1002/ehf2.13605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/02/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
AIMS This study aimed to identify echocardiographic determinants of left ventricular thrombus (LVT) formation after acute anterior myocardial infarction (MI). METHODS AND RESULTS This case-control study comprised 55 acute anterior MI patients with LVT as cases and 55 acute anterior MI patients without LVT as controls, who were selected from a cohort of consecutive patients with ischemic heart failure in our hospital. The cases and controls were matched for age, sex, and left ventricular ejection fraction. LVT was detected by routine/contrast echocardiography or cardiac magnetic resonance imaging during the first 3 months following MI. Formation of apical aneurysm after MI was independently associated with LVT formation [72.0% vs. 43.5%, odds ratio (OR) = 5.06, 95% confidence interval (CI) 1.65-15.48, P = 0.005]. Echocardiographic risk factors associated with LVT formation included reduced mitral annular plane systolic excursion (<7 mm, OR = 4.69, 95% CI 1.84-11.95, P = 0.001), moderate-severe diastolic dysfunction (OR = 2.71, 95% CI 1.11-6.57, P = 0.028), and right ventricular (RV) dysfunction [reduced tricuspid annular plane systolic excursion < 17 mm (OR = 5.48, 95% CI 2.12-14.13, P < 0.001), reduced RV fractional area change < 0.35 (OR = 3.32, 95% CI 1.20-9.18, P = 0.021), and enlarged RV mid diameter (per 5 mm increase OR = 1.62, 95% CI 1.12-2.34, P = 0.010)]. Reduced tricuspid annular plane systolic excursion (<17 mm) significantly associated with increased risk of LVT in anterior MI patients (OR = 3.84, 95% CI 1.37-10.75, P = 0.010), especially in those patients without apical aneurysm (OR = 5.12, 95% CI 1.45-18.08, P = 0.011), independent of body mass index, hypertension, anaemia, mitral annular plane systolic excursion, and moderate-severe diastolic dysfunction. CONCLUSIONS Right ventricular dysfunction as determined by reduced TAPSE or RV fractional area change is independently associated with LVT formation in acute anterior MI patients, especially in the setting of MI patients without the formation of an apical aneurysm. This study suggests that besides assessment of left ventricular abnormalities, assessment of concomitant RV dysfunction is of importance on risk stratification of LVT formation in patients with acute anterior MI.
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Affiliation(s)
- Mengjia Chen
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Dan Liu
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Frank Weidemann
- Medizinischen Klinik I des Klinikum VestRecklinghausenGermany
| | - Björn Daniel Lengenfelder
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Georg Ertl
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Kai Hu
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Stefan Frantz
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Peter Nordbeck
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
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Abstract
A 27-year-old Caucasian male traveler with well-controlled asthma was admitted to our hospital because of severe heart failure (HF). He had a history of cocaine use. Transthoracic echocardiography (TTE) showed severe diffuse hypokinesis of the left ventricle (LV) and a large mobile thrombus in the LV. He was treated with diuretics, inotropes and anticoagulants which led to small improvements in the HF and LV thrombus, however, he needed to undergo left ventricular assist device (LVAD) implantation and surgical removal of a residual LV thrombus due to inotrope-dependency.It is necessary to consider the possibility of cocaine or illicit drug use in a young individual with cardiovascular disease or sudden death even in Japan where cocaine and drugs are prohibited by law, as recreational drug use has been increasing in many countries around the world.
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Affiliation(s)
- Norifumi Bekki
- Department of Cardiology, National Center for Global Health and Medicine
| | - Hiromasa Hayama
- Department of Cardiology, National Center for Global Health and Medicine
| | - Rina Ishii
- Department of Cardiology, Odawara Cardiovascular Hospital
| | - Toru Awaya
- Department of Cardiology, Toho University Ohashi Medical Center
| | - Tetsuya Horai
- Department of Cardiovascular Surgery, National Center for Global Health and Medicine
| | - Hisao Hara
- Department of Cardiology, National Center for Global Health and Medicine
| | - Yukio Hiroi
- Department of Cardiology, National Center for Global Health and Medicine
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Mihm AE, Hicklin HE, Cunha AL, Nisly SA, Davis KA. Direct oral anticoagulants versus warfarin for the treatment of left ventricular thrombosis. Intern Emerg Med 2021; 16:2313-2317. [PMID: 34165680 DOI: 10.1007/s11739-021-02788-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Alexandra Evaun Mihm
- Department of Pharmacy, Atrium Health, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Harry Eugene Hicklin
- Department of Internal Medicine, Atrium Health, Wake Forest School of Medicine, Winston Salem, NC, 27157, USA
| | - Alexandra Lee Cunha
- Department of Pharmacy, Atrium Health, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
- Fred Wilson School of Pharmacy, High Point University, High Point, NC, 27268, USA
| | - Sarah Anne Nisly
- Department of Pharmacy, Atrium Health, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
- School of Pharmacy, Wingate University, Wingate, NC, 28174, USA
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Patel AS, Cronin EM. Catheter ablation of atrial arrhythmias to prevent ventricular tachycardia in a patient with mobile left ventricular thrombus. HeartRhythm Case Rep 2021; 7:687-690. [PMID: 34712566 PMCID: PMC8530904 DOI: 10.1016/j.hrcr.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Arjun S Patel
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Edmond M Cronin
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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Munoz D, Malik H, Eickenhorst D, Newman S, Varughese C, Ali F. Cardiac Screening in a Young Adult Male Leading to Discovery of Post-COVID Myocarditis with Asymptomatic Large Apical Left Ventricular Thrombus. CASE (Phila) 2021; 5:309-312. [PMID: 34712875 PMCID: PMC8530822 DOI: 10.1016/j.case.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A unique sequela of COVID-19 is COVID-related ventricular thrombus formation. Diagnosis of a ventricular thrombus can only be confirmed through imaging. COVID-related myocarditis can ultimately lead to ventricular thrombus formation. Post-COVID cardiac screening may reveal sequelae in asymptomatic athletic individuals.
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Affiliation(s)
- David Munoz
- Department of Internal Medicine, Medical City Weatherford, Weatherford, Texas
| | - Hamza Malik
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Daniel Eickenhorst
- Department of Radiology, Baylor Scott and White All Saints, Fort Worth, Texas
| | - Stephen Newman
- Department of Cardiology, Baylor Scott and White All Saints, Fort Worth, Texas
| | - Cyril Varughese
- Department of Cardiology, Baylor Scott and White All Saints, Fort Worth, Texas
| | - Farhan Ali
- Department of Cardiology, Baylor Scott and White All Saints, Fort Worth, Texas
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De Luca L, Putini RL, Natale E, Terranova A, Piazza V, Pugliese M, De Lio L, Biffani E, Bellettini E, Uguccioni M, Musumeci F. One-year clinical outcome of patients with left ventricular thrombus after acute myocardial infarction discharged on triple or dual antithrombotic therapy. J Thromb Thrombolysis 2021; 53:410-416. [PMID: 34613575 DOI: 10.1007/s11239-021-02577-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/30/2022]
Abstract
In patients with left ventricular thrombus (LVT) after acute myocardial infarction (MI), both anticoagulant and antiplatelet therapies are needed. It is unknown whether dual antithrombotic therapy (DAT) is able to reduce the incidence of bleeding complications without significantly increasing the number of thromboembolic events, compared to triple antithrombotic therapy (TAT). We retrospectively evaluated all post-MI patients with LVT discharged on TAT or DAT from our tertiary hospital in the last decade. The primary outcome was the occurrence of all-cause mortality, thromboembolic events, hospitalizations for re-MI or heart failure and any bleeding at 1 year. A propensity-score matching was performed in order to compare the primary outcome between TAT and DAT. Out of 2564 acute MI patients, 83 (3.2%) had an LVT at echocardiography: 51 (61.4%) discharged on TAT and 32 (38.6%) on DAT. At clinical follow-up, completed in 93% of cases, the incidence of the primary outcome was 18.2% (25.5% in TAT and 6.7% in DAT group; p = 0.04). More than 2/3 of the events included in the primary outcome were related to bleeding complications and occurred during the first month from hospital discharge. In the matched cohort of 42 patients with follow-up data available, the primary outcome occurred in 9 (42.9%) patients in the TAT and 2 (9.5%) in the DAT group (p = 0.03). In post-MI patients with LVT, DAT seems more effective than TAT in reducing clinical outcome, especially early bleeding complications. A randomized study is warranted to confirm this hypothesis.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
| | - Rita Lucia Putini
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Enrico Natale
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Antonio Terranova
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Vito Piazza
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Marco Pugliese
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Lucia De Lio
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Elisabetta Biffani
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Elisa Bellettini
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Massimo Uguccioni
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Francesco Musumeci
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
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Eranki A, Villanueva C, Collins N, Seah P. Video assisted, transaortic removal of left ventricular thrombus during concurrent cardiac surgery: a case report. J Cardiothorac Surg 2021; 16:242. [PMID: 34446037 PMCID: PMC8390245 DOI: 10.1186/s13019-021-01626-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Left ventricular (LV) thrombus is a complication of acute myocardial infarction and is associated with systemic thromboembolism. We describe a trans-aortic endoscopic approach to the removal of an LV thrombus in a patient undergoing concurrent coronary artery bypass grafting and aortic valve replacement. Case presentation A 47 year old male presented following an embolic middle cerebral artery stroke and underwent transthoracic echocardiography demonstrating a mobile LV thrombus. Additional investigation revealed a moderately stenosed bicispid aortic valve, two vessel coronary artery disease and ischemic cardiomyopathy. The patient underwent early surgery to reduce the risk of further embolic episodes. A trans-aortic approach was utilized with videoscopy and single shafted instrumentation to aide in removal of the thrombus. The patient then underwent aortic valve replacement and coronary artery bypass grafting. Conclusion We report an alternative technique for the removal of a left ventricular thrombus in a patient undergoing concurrent coronary and aortic valve surgery. The transaortic video-assisted approach provided excellent visualisation of the apex and near complete removal of the thrombus without damaging the surrounding trabeculae. The main benefit of this technique is sparing of LV tissue, thereby preserving left ventricular function.
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Affiliation(s)
| | | | | | - Peng Seah
- John Hunter Hospital, Newcastle, Australia
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Zhang Z, Si D, Zhang Q, Qu M, Yu M, Jiang Z, Li D, Yang P, Zhang W. Rivaroxaban versus Vitamin K Antagonists (warfarin) based on the triple therapy for left ventricular thrombus after ST-Elevation myocardial infarction. Heart Vessels 2021; 37:374-384. [PMID: 34420077 DOI: 10.1007/s00380-021-01921-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Left ventricular thrombus (LVT) can complicate ST-Elevation myocardial infarction (STEMI) and is associated with poor outcomes. Conventional triple anticoagulation [Vitamin K Antagonists (VKA) plus dual-antiplatelet therapy (DAPT)] is the first-line therapy for LVT after STEMI. In patients with LVT following STEMI, contemporary data of triple therapy with rivaroxaban are lacking. METHODS We conducted a retrospective cohort study involving 1335 STEMI patients who underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we observed differences in efficacy between rivaroxaban plus DAPT therapy and VKA plus DAPT. The time of LVT resolution was also evaluated, as well as net clinical adverse events, and rates of bleeding events. RESULTS In 1335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow-up period (median 25.0 months). Of the patients diagnosed with LVT, 31 patients were started on triple therapy with VKA, 33 patients on triple therapy with rivaroxaban. There was a consistent similarity in LVT resolution with rivaroxaban application compared to VKA application during the follow-up period [HR (log-rank test) 1.57(95% CI 0.89-2.77), p = 0.096; Adjusted HR 1.70(95% CI 0.90-3.22), p = 0.104]. Triple therapy with rivaroxaban showed quicker resolution than with VKA (6 months: p = 0.049; 12 months: p = 0.044; 18 months: p = 0.045). Similar risks of ISTH bleeding were not significantly different between the 2 groups [VKA 9.7% vs Rivaroxaban 6.1%, Adjusted HR 0.48 (95% CI 0.73-3.20); p = 0.444)]. Fewer net adverse clinical events (NACE) were observed in the rivaroxaban group [VKA 58.1% vs Rivaroxaban 24.2%; HR (log-rank test) 0.31(95% CI 0.14-0.68), p = 0.003; Adjusted HR 0.23(95% CI 0.09-0.57), p = 0.001]. CONCLUSION In the observational study, triple therapy with rivaroxaban has similar and quicker LVT resolution in patients with LVT after STEMI, compared with triple therapy with VKA, and perhaps was associated with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.
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Affiliation(s)
- Zhongfan Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Daoyuan Si
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Qian Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Ming Qu
- Department of Gastroenterology, Endoscopy Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Miao Yu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Zhenya Jiang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Delin Li
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Ping Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Wenqi Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China.
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Alcalai R, Butnaru A, Moravsky G, Yagel O, Rashad R, Ibrahimli M, Planer D, Amir O, Elbaz-Greener G, Leibowitz D. Apixaban versus Warfarin in Patients with Left Ventricular Thrombus, A Prospective Multicenter Randomized Clinical Trial. Eur Heart J Cardiovasc Pharmacother 2021; 8:660-667. [PMID: 34279598 DOI: 10.1093/ehjcvp/pvab057] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/06/2021] [Accepted: 07/14/2021] [Indexed: 12/23/2022]
Abstract
AIMS Current guidelines recommend anticoagulation with a vitamin K antagonist to treat left ventricular (LV) thrombus post myocardial infarction (MI). Data on the use of direct oral anticoagulants (DOACS) in this setting is limited. The aim of the study was to assess the efficacy of apixaban versus warfarin in treating LV thrombus after MI. METHODS AND RESULTS A prospective, randomized, multi-center open label clinical trial including patients with LV thrombus detected by 2D-transthoracic-echocardiography 1-14 days after acute MI. Thirty-five patients were enrolled in 3 medical centers, 17 patients were randomized to warfarin and 18 patients to apixaban. The primary outcome was the presence and size of LV thrombus 3 months after initiation of anticoagulation. Secondary outcomes were major bleeding, stroke or systemic embolism, re-hospitalization, and all-cause mortality. Mean LV thrombus size at enrollment was 18.5 × 12.3 mm in the warfarin group and 19.9 × 12.4 mm in the apixaban group (P = NS). Thirty-two patients completed 3 months follow-up. In the warfarin group two patients withdrew and in the apixaban group one patient died. Thrombus completely resolved in 14 of 15 patients in the warfarin group and in 16 of 17 in the apixaban group ((P = NS, P = 0.026 for non-inferiority). Two patients had major bleeding in the warfarin group while no major bleeding events were recorded in the apixaban group. There was one stroke in the warfarin group and one death in the apixaban group. CONCLUSION Our results suggest that apixaban is non-inferior to warfarin for treatment of patients with LV thrombus after acute MI with a 20% non-inferiority margin.
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Affiliation(s)
- Ronny Alcalai
- Department of Cardiology, Hadassah Medical Center and faculty of medicine, Hebrew University of Jerusalem, Israel
| | - Adi Butnaru
- Heart Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Gil Moravsky
- Cardiology department, Shamir Medical Center, Tzrifin, Israel
| | - Oren Yagel
- Department of Cardiology, Hadassah Medical Center and faculty of medicine, Hebrew University of Jerusalem, Israel
| | - Razek Rashad
- Department of Cardiology, Hadassah Medical Center and faculty of medicine, Hebrew University of Jerusalem, Israel
| | - Mahsati Ibrahimli
- Department of Cardiology, Hadassah Medical Center and faculty of medicine, Hebrew University of Jerusalem, Israel
| | - David Planer
- Department of Cardiology, Hadassah Medical Center and faculty of medicine, Hebrew University of Jerusalem, Israel
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center and faculty of medicine, Hebrew University of Jerusalem, Israel
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center and faculty of medicine, Hebrew University of Jerusalem, Israel
| | - David Leibowitz
- Department of Cardiology, Hadassah Medical Center and faculty of medicine, Hebrew University of Jerusalem, Israel
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Zhang PY, Becher H, Jeerakathil T, Graham MM, Shanks M. The incidence of stroke in patients with early echocardiography after acute myocardial infarction. Int J Cardiovasc Imaging 2021; 37:3423-3429. [PMID: 34251550 DOI: 10.1007/s10554-021-02333-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/25/2021] [Indexed: 01/03/2023]
Abstract
Left ventricular (LV) thrombus formation after ST-elevation myocardial infarction (STEMI) increases the risk of stroke. In our center, most echocardiograms are performed within 2 days post-STEMI. However, LV thrombi often become visible later. We assessed the 1-year incidence of stroke in patients without LV thrombus on echocardiography performed early (1-2 days) vs. later (day ≥ 3) post-STEMI. This retrospective observational study included 416 patients with acute STEMI. Patients with atrial fibrillation were excluded. All patients underwent echocardiography during admission. Patients with stroke within 12 months post-STEMI were identified from the hospital charts and administrative databases. Most echocardiograms (75%) were performed ≤ 2 days post-STEMI. LV thrombus was identified in 12 patients. One (8.3%) patient with LV thrombus and 10 (2.5%) patients without LV thrombus suffered stroke within 12 months post-STEMI. Most patients with stroke had apical akinesis. Most strokes occurred during the index admission or within 67 days of STEMI. There was no significant difference in the incidence of stroke between the patients with early vs. later echocardiography post-STEMI. The incidence of stroke after STEMI is low and similar between patients with echocardiography performed early vs. later post-STEMI which supports our current clinical practice. Importantly, most strokes occur in patients without LV thrombus on early echocardiography. High reported mortality rate associated with stroke following STEMI justifies the need for further validation in prospective studies to identify patients who may benefit from repeat imaging to detect later LV thrombus formation, and how this will impact patient outcomes and healthcare costs.
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Affiliation(s)
- Peter Yuan Zhang
- Division of Cardiology, Department of Medicine, 2C2 Walter Mackenzie Health Sciences Center, Mazankowski Alberta Heart Institute, University of Alberta, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Harald Becher
- Division of Cardiology, Department of Medicine, 2C2 Walter Mackenzie Health Sciences Center, Mazankowski Alberta Heart Institute, University of Alberta, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Michelle M Graham
- Division of Cardiology, Department of Medicine, 2C2 Walter Mackenzie Health Sciences Center, Mazankowski Alberta Heart Institute, University of Alberta, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Miriam Shanks
- Division of Cardiology, Department of Medicine, 2C2 Walter Mackenzie Health Sciences Center, Mazankowski Alberta Heart Institute, University of Alberta, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada.
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Abdelaziz HK, Megaly M, Debski M, Abdelrahman A, Abdelaziz S, Kamal D, Patel B, More R, Choudhury T. Meta-Analysis Comparing Direct Oral Anticoagulants to Vitamin K Antagonists for The Management of Left Ventricular Thrombus. Expert Rev Cardiovasc Ther 2021; 19:427-432. [PMID: 33830867 DOI: 10.1080/14779072.2021.1915134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: To compare vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) treatment in patients with left ventricular (LV) thrombus. The primary outcome was stroke or systemic embolism (SSE). Secondary outcomes were thrombus resolution, bleeding, and death.Areas covered: Five observational studies were included (total n = 700; VKAs n = 480; DOACs n = 220). There was a trend toward less SSE with VKAs compared to DOACs (5.2% vs. 9%; odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.29-1.01, p = 0.05). No significant difference between VKAs and DOACs in rates of thrombus resolution (61.6% vs. 56.8%; OR = 1.00, 95% CI = 0.58-1.73, p = 0.99), bleeding (8.2% vs. 4.4%; OR = 1.62, 95% CI = 0.69-3.77, p = 0.27), or death (12.7% vs. 11.8%; OR = 1.09, 95% CI = 0.59-2.0, p = 0.79) was noted. In non-primary percutaneous coronary intervention setting, VKAs were associated with less SSE in prespecified analysis (5.2% vs.10.6%; OR = 0.48, 95% CI = 0.25-0.93, p = 0.03).Expert opinion: The current meta-analysis suggests a trend toward higher SSE with the use of DOACs compared to VKAs. Our recommendation is for VKAs to retain the preferred management of LV thrombus with cautious off-label use of DOACs.
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Affiliation(s)
- Hesham K Abdelaziz
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, UK.,Ain Shams Medical School, Ain Shams University, Cairo, Egypt
| | - Michael Megaly
- Banner University Medical Center, UA College of Medicine, Phoenix, AZ, USA
| | - Maciej Debski
- Norfolk and Norwich University Hospital and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Amr Abdelrahman
- Cardiology Department, Airedale NHS Foundation Trust, Airedale, UK
| | | | - Diaa Kamal
- Ain Shams Medical School, Ain Shams University, Cairo, Egypt
| | - Billal Patel
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, UK
| | - Ranjit More
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, UK
| | - Tawfiq Choudhury
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, UK
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Abukhodair A, Alqarni MS, Alzahrani A, Bukhari ZM, Zuber K, Alzahrani A. Large left ventricular thrombus surgically resected in a patient with normal ejection: A case report. Int J Surg Case Rep 2021; 81:105842. [PMID: 33887846 DOI: 10.1016/j.ijscr.2021.105842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 11/20/2022] Open
Abstract
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.
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Koizumi S, Ishida K. Endoscopy-assisted removal of multiple left ventricular thrombi through right mini-thoracotomy. Gen Thorac Cardiovasc Surg 2021; 69:1140-3. [PMID: 33743136 DOI: 10.1007/s11748-021-01622-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
Left ventricular thrombus is life-threatening when it causes systemic embolization. In cases with a high risk of systemic embolization, left ventricular thrombectomy is recommended. However, the optimal surgical approach is unclear, especially for non-ischemic cardiomyopathy, because left ventriculotomy carries the risk of postoperative cardiac dysfunction. We herein report a male patient with multiple left ventricular thrombi due to acute myocarditis. Endoscopy-assisted left ventricular thrombectomy through right mini-thoracotomy was successfully performed. This method might be an efficient and less-invasive left ventricular thrombectomy for non-ischemic cardiomyopathy.
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45
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Lemaître AI, Picard F, Maurin V, Faure M, Dos Santos P, Girerd N. Clinical profile and midterm prognosis of left ventricular thrombus in heart failure. ESC Heart Fail 2021; 8:1333-1341. [PMID: 33629818 PMCID: PMC8006720 DOI: 10.1002/ehf2.13211] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/07/2020] [Accepted: 01/02/2021] [Indexed: 12/30/2022] Open
Abstract
Aims We documented the midterm prognosis of left ventricular thrombus (LVT) in heart failure (HF) patients with dilated cardiomyopathy (DCM) and ischaemic cardiomyopathy (ICM). We aimed to characterize patients with LVT in the context of HF with reduced (≤40%) left ventricular ejection fraction and evaluate their risk for death and/or embolic events, overall, and specifically in patients with ischaemic or non‐ischaemic aetiology. We also intended to identify risk factors for LVT in patients with DCM. Methods and results We included all HF patients (N = 105, age 56 ± 13) admitted from 2005 to 2018 in our institution for LVT without significant valve disease/prosthesis, heart transplant/left ventricular assist device, congenital heart disease, or acute myocardial infarction. Our primary endpoint was the 1 year risk of the composite of all‐cause mortality (ACM) and symptomatic embolic events. Mean left ventricular ejection fraction was 23 ± 9%, and median BNP was 1795 pg/mL. Most (97%) patients were treated with vitamin K anticoagulants, and 64% had ICM. Symptomatic embolic events and/or ACM occurred in 20% of the population [embolic events (all within 30 days of LVT diagnosis) 15% and ACM 6%] and was similarly frequent in DCM or ICM (P > 0.05). Suspected/transient embolic events were more frequent in DCM (overall 13%; 29% in DCM vs. 5% in ICM, P < 0.01). Major bleeding occurred in 5% of patients. Left ventricular reverse remodelling occurred in 65% of patients, more frequently in DCM (86% in DCM vs. 65% in ICM, P = 0.02). In a case–control analysis matching DCM patients, BNP level was the only factor significantly associated with LVT (2447 pg/mL in LVT vs. 347 pg/mL, P < 0.001). Conclusions Patients with LVT have markedly high natriuretic peptides and experience a 20% 1 year risk for embolic events and/or death following diagnosis despite anticoagulant treatment. Most patients have favourable remodelling/recovery. As all symptomatic embolic events occurred within 30 days of LVT diagnosis, a very careful initial management is warranted.
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Affiliation(s)
| | | | | | - Maxime Faure
- Bordeaux University Hospital (CHU), Bordeaux, France
| | - Pierre Dos Santos
- Bordeaux University Hospital (CHU), Bordeaux, France.,Centre de Recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,IHU Liryc, Electrophysiology and Heart Modelling Institute, Foundation Bordeaux Université, Bordeaux, France
| | - Nicolas Girerd
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU Nancy, and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
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46
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Dalia T, Lahan S, Ranka S, Goyal A, Zoubek S, Gupta K, Shah Z. Warfarin versus direct oral anticoagulants for treating left ventricular thrombus: a systematic review and meta-analysis. Thromb J 2021; 19:7. [PMID: 33517885 PMCID: PMC7849079 DOI: 10.1186/s12959-021-00259-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/17/2021] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Tarun Dalia
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shubham Lahan
- University College of Medical Sciences, New Delhi, India
| | - Sagar Ranka
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Amandeep Goyal
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sara Zoubek
- Department of Pharmacology, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kamal Gupta
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Zubair Shah
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
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Liu X, Lei S, Huang H, Wu Y, Hu ZX. Resolution of huge thrombi in bilateral ventricles caused by severe lupus cardiomyopathy. Lupus 2021; 30:840-844. [PMID: 33497305 DOI: 10.1177/0961203321989808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Ventricular thrombus is an uncommon, severe condition with high morbidity and mortality. Simultaneous left and right ventricular thrombi caused by lupus myocardiopathy have not been previously reported in the literature. This case presents a 42-year-old woman who has bilateral ventricular thrombi with reduced left ventricular ejection fraction (35.4%) and acute kidney injury. Pro-brain natriuretic peptide was >35000 pg/mL. Systemic lupus erythematosus was confirmed based on multiorgan injuries including malar rash, anemia, renal injury, positive antinuclear, anti-Smith antibodies, and decreased complements. Renal biopsy revealed lupus nephritis class III + V. Low molecular weight heparin, steroids, and mycophenolate mofetil were initiated, after which the patient experienced transient numbness in the right limbs and hemoptysis. She then recovered quickly and improved significantly with recovery of left ventricular systolic function (left ventricular ejection fraction 46%) and the eventual disappearance of thrombi. Simultaneous left and right ventricular thrombi are rare but life-threatening condition, prompting consideration of myocardiopathy caused by autoimmune diseases such as lupus. Timely treatment with immunosuppressants and anticoagulants may resolve the thrombi and improve cardiac function.
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Affiliation(s)
- Xinyi Liu
- *These authors contributed equally to this work.,Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Song Lei
- *These authors contributed equally to this work.,Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - He Huang
- *These authors contributed equally to this work.,Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Wu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhang-Xue Hu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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Zhou X, Shi R, Wu G, Zhu Q, Zhou C, Wang L, Xue C, Jiang Y, Cai X, Huang W, Shan P. The prevalence, predictors, and outcomes of spontaneous echocardiographic contrast or left ventricular thrombus in patients with HFrEF. ESC Heart Fail 2021; 8:1284-1294. [PMID: 33496071 PMCID: PMC8006613 DOI: 10.1002/ehf2.13196] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/12/2020] [Accepted: 12/23/2020] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Xiaodong Zhou
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Ruiyu Shi
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Gaojun Wu
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Qianli Zhu
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Changzuan Zhou
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Liangguo Wang
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Chenglong Xue
- Department of Cardiology, Longgang City People's Hospital, Longgang, Zhejiang, China
| | - Yuanyuan Jiang
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Xueli Cai
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Weijian Huang
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China
| | - Peiren Shan
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, 325000, China.,Department of Cardiology, Longgang City People's Hospital, Longgang, Zhejiang, China
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Tan S, Thakur U, Chow KY, Lee S, Ngoi A, Nerlekar N, Nasis A. Predictive utility of left heart catheterization indices for left ventricular thrombus formation after anterior ST-elevation myocardial infarction. Cardiovasc Revasc Med 2021; 34:106-111. [PMID: 33461935 DOI: 10.1016/j.carrev.2021.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/22/2020] [Accepted: 01/12/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Left ventricular thrombus (LVT) has a 5% incidence after anterior ST-elevation myocardial infarction (STEMI). Multiple risk factors predispose to LVT formation, including left ventricular systolic dysfunction and infarct size, however measurable predictors during index left heart catheterization (LHC) have not been determined. METHODS We performed a retrospective analysis of patients presenting between January 2010 and September 2017 with anterior STEMI who had in-hospital transthoracic echocardiography (TTE). LHC variables that were assessed included coronary anatomy, location of culprit stenosis, presence of diffuse stenosis, number of severely diseased vessels, apical akinesis on left ventriculogram (LVG), left ventricular end diastolic pressure, and success of percutaneous coronary intervention (PCI). RESULTS Of 598 consecutive anterior STEMI patients, records and inpatient TTE results were available in 425 patients. The incidence of LVT was 6.8% (n = 29). After multivariate adjustment, severe triple vessel coronary disease (OR = 8.27, CI = 2.97-23.00, p ≤0.001), apical akinesis on LVG (OR = 6.74, CI = 1.48-30.73, p = 0.014), wrap-around left anterior descending (LAD) anatomy (OR = 5.10, CI = 1.97-13.23, p = 0.001), and failure of recanalization after PCI (OR = 3.94, CI = 1.06-14.66, p = 0.04) were predictors for LVT formation. The combined negative predictive value (NPV) for the absence of these four indices was 99.2%. CONCLUSION Severe triple vessel disease, apical akinesis on LVG during index admission, wrap-around LAD, and failure of recanalization after PCI are associated with increased risk of LVT formation after anterior STEMI. The high NPV for the absence of these indices could serve as a risk stratification tool for LVT risk to guide early TTE utilization.
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Affiliation(s)
- Sean Tan
- MonashHeart, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia.
| | - Udit Thakur
- MonashHeart, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Kuan Yee Chow
- Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3350, Australia
| | - Senhong Lee
- Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Andy Ngoi
- Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Nitesh Nerlekar
- MonashHeart, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia; Monash University, Wellington Road, Clayton, Victoria 3800, Australia
| | - Arthur Nasis
- MonashHeart, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia; Monash University, Wellington Road, Clayton, Victoria 3800, Australia.
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50
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Bass ME, Kiser TH, Page RL, McIlvennan CK, Allen LA, Wright G, Shakowski C. Comparative effectiveness of direct oral anticoagulants and warfarin for the treatment of left ventricular thrombus. J Thromb Thrombolysis 2021; 52:517-522. [PMID: 33420896 DOI: 10.1007/s11239-020-02371-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/05/2023]
Abstract
Left ventricular (LV) thrombus is a complication of acute endomyocardial injury and chronic ventricular wall hypokinesis, resulting in increased risk of thromboembolic complications. Observational studies support the general safety and efficacy of warfarin for this indication. Limited data exists regarding the use of direct oral anticoagulants (DOACs) for LV thrombus. This retrospective cohort study sought to compare the incidence of thromboembolic events, bleeding rates, and blood product administration in patients receiving a DOAC versus warfarin. A total of 949 patients met inclusion, 180 (19%) received a DOAC and 769 (81%) warfarin. For the primary endpoint of new onset thromboembolic stroke, no difference existed between treatments (DOAC: 7.8% vs warfarin: 11.7%, p = 0.13). When compared to warfarin, no difference existed in the composite of thromboembolic events (33% vs 30.6%, p = 0.53, respectively) or in GUSTO bleeding (10.9% vs 7.8%, p = 0.40, respectively). More patients on warfarin received blood products compared to those taking a DOAC (25.8% vs 13.9%, p < 0.001).DOACs may be an alternative to warfarin for the treatment of LV thrombus based on a retrospective assessment of thromboembolic events and GUSTO bleeding events within 90 days of diagnosis of LV thrombus. However, further prospective studies are warranted.
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Affiliation(s)
- Megan E Bass
- Department of Pharmacy, UCHealth - University of Colorado Hospital, 12505 E. 16th Avenue, Aurora, CO, 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Robert L Page
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Colleen K McIlvennan
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Larry A Allen
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Garth Wright
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Courtney Shakowski
- Department of Pharmacy, UCHealth - University of Colorado Hospital, 12505 E. 16th Avenue, Aurora, CO, 80045, USA.
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