Incidence and Predictors of Left Ventricular Thrombus After Primary Percutaneous Coronary Intervention for Anterior ST-Segment Elevation Myocardial Infarction

A Comprehensive Review: Epidemiological strategies, Catheterization and Biomarkers used as a Bioweapon in Diagnosis and Management of Cardio Vascular Diseases

Coronary artery disease (CAD) is a serious health problem that causes a considerable number of mortality in a number of affluent nations throughout the world. The estimated death encountered in many developed countries includes including Pakistan, reached 111,367 and accounted for 9.87% of all deaths, despite the mortality rate being around 7.2 million deaths per year, or 12% of all estimated deaths accounted annually around the globe, with improved health systems. Atherosclerosis progressing causes the coronary arteries to become partially or completely blocked, which results in CAD. Additionally, smoking, diabetes mellitus, homocystinuria, hypertension, obesity, hyperlipidemia, and psychological stress are risk factors for CAD. The symptoms of CAD include angina which is described as a burning, pain or discomfort in the chest, nausea, weakness, shortness of breath, lightheadedness, and pain or discomfort in the arms or shoulders. Atherosclerosis and thrombosis are the two pathophysiological pathways most frequently involved in acute coronary syndrome (ACS). Asymptomatic plaque disruption, plaque bleeding, symptomatic coronary blockage, and myocardial infarction are the prognoses for CAD. In this review, we will focus on medicated therapy which is being employed for the relief of angina linked with CAD including antiplatelet medicines, nitrates, calcium antagonists, blockers, catheterization, and the frequency of recanalized infarct-related arteries in patients with acute anterior wall myocardial infarction (AWMI). Furthermore, we have also enlightened the importance of biomarkers that are helpful in the diagnosis and management of CAD.

Contemporary incidence and predictors of left ventricular thrombus in patients with anterior acute myocardial infarction

BACKGROUND

The incidence of left ventricular thrombus (LVT) after anterior acute myocardial infarction (AMI) has not been well established in the era of primary percutaneous coronary intervention (pPCI) and potent dual antiplatelet therapy. The objective of this study is to establish the contemporary incidence of LVT in this population, to identify their risk factors, and to examine their association with clinical outcomes.

METHODS

A multicenter retrospective cohort study including AMI patients with new-onset antero-apical wall motion abnormalities treated with pPCI between 2009 and 2017 was conducted. The primary outcome was LVT during the index hospitalization. Predictors of LVT were identified using multivariate logistic regression. Net adverse clinical events (NACE), a composite of mortality, myocardial infarction, stroke or transient ischemic attack, systemic thromboembolism or BARC type 3 or 5 bleeding at 6 months were compared between the LVT and no LVT groups.

RESULTS

Among the 2136 patients included, 83 (3.9%) patients developed a LVT during index hospitalization. A lower left ventricular ejection fraction (LVEF) [adjusted odds ratio (aOR) 0.97; 95% confidence intervals (CI) 0.94-0.99] and the degree of worse anterior WMA (aOR 4.34; 95% CI 2.24-8.40) were independent predictors of LVT. A NACE occurred in 5 (5.72 per 100 patient-year) patients in the LVT group and in 127 (6.71 per 100 patient-year) patients in the no LVT group at 6 months [adjusted hazard ratio (aHR): 0.87; 95% CI 0.35-2.14].

CONCLUSIONS

The risk of LVT after anterior AMI with new-onset wall motion abnormalities is low, but this complication remains present in the contemporary era of timely pPCI and potent dual antiplatelet therapy .

Aneurysmal degeneration in the Omniflow II biosynthetic vascular graft

Despite advances in endovascular treatments, femoropopliteal bypass is still the best option for the treatment of lower-extremity occlusive artery disease. Omniflow II biosynthetic vascular grafts are often chosen as bypass grafts when autologous vein grafting is not possible. A negative feature of this graft is the tendency towards late biodegeneration with possible formation of graft aneurysms. In this case report, we present a thrombosed non-anastomotic biosynthetic graft aneurysm, which caused only a pulsatile mass in the inguinal region, in a 62-year-old male patient who had undergone a femoropopliteal bypass operation three years earlier. Aneurysm formation in vascular grafts is multifactorial and can cause life-threatening consequences. Therefore, all patients with biosynthetic vascular grafts should remain under lifetime surveillance with duplex ultrasound for aneurysmal graft degeneration and graft thrombosis.

An unusually large left ventricular thrombus complicating anterior myocardial infarction: the value of multimodality imaging

Since the emergence of revascularisation for the treatment of myocardial infarction (MI), the incidence of left ventricular thrombus (LVT) has been declining. However, despite this, it is independently associated with increased morbidity and mortality rates. The mainstay of treatment is vitamin K antagonists, although non-vitamin K antagonists have been shown to be effective. Imaging plays an important role in the surveillance of LVT subsequent to MI. Herein, we emphasise the utility of multimodality imaging of a case of anterior MI complicated by a large LVT, and detail its management.

Case report: Oral anticoagulant combined with percutaneous coronary intervention for peripheral embolization of left ventricular thrombus caused by myocardial infarction in a patient with diabetes mellitus

Background

Left ventricular thrombus (LVT) is a well-recognized complication of myocardial infarction (MI) in patients with diabetes. An embolic complication caused by LVT is a key clinical problem and is associated with worsened long-term survival.

Case presentation

A 45-year-old man with persistent left abdominal pain for 1 week and left leg fatigue was admitted to the emergency department. The cause of abdominal pain was embolism of the renal artery, the splenic artery, and the superior mesenteric artery caused by cardiogenic thrombosis, which further led to splenic infarction and renal infarction. It was unclear when MI occurred because the patient had no typical critical chest pain, which may have been related to diabetic complications, such as diabetic peripheral neuropathy. Diabetes plays a pivotal role in MI and LVT formation. Because coronary angiography suggested triple vessel disease, percutaneous transluminal coronary angioplasty (PTCA) was conducted, and two drug-eluting stents were placed in the left anterior descending coronary artery (LAD). Due to a lack of randomized clinical control trials, the therapy of LVT and associated embolization has been actively debated. According to the present guidelines, this patient was treated with low-molecular-weight heparin and warfarin (oral anticoagulants) for 3 months in addition to aspirin (100 mg/day) and clopidogrel (75 mg/day) for 1 year. No serious bleeding complications were noted, and a follow-up examination showed no thrombus in the left ventricle or further peripheral thrombotic events.

Conclusion

Peripheral embolization of LVT caused by MI leading to multiple organ embolization remains a rare occurrence. Diabetes plays a pivotal role in MI and LVT formation. Successful revascularization of the infarct-related coronary artery and anticoagulation therapy is important to minimize myocardial damage and prevent LVT. The present case will help clinicians recognize and manage LVT in patients with diabetes and related peripheral arterial thrombotic events with anticoagulation.

Factors Impacting Stent Thrombosis in Patients With Percutaneous Coronary Intervention and Coronary Stenting: A Systematic Review and Meta-Analysis

Stent thrombosis (ST) is a frequently reported complication in cardiac patients with percutaneous coronary intervention (PCI) that adversely impacts their prognostic outcomes. Medical literature reveals several baseline characteristics of PCI patients that may predict their predisposition to ST and its potential complications. Our systematic review and meta-analysis aimed to determine the diagnostic significance of these baseline parameters in terms of determining the risk of ST among adult patients with PCI. 

We statistically evaluated 18 baseline characteristics of more than 15,500 PCI patients to delineate their stent thrombosis attribution. We included a number of articles focusing on baseline parameters in-stent thrombosis-related PCI scenarios. We explored the articles of interest based on inclusion/exclusion parameters across PubMed, JSTOR, Cochrane library, Google Scholar, and Embase. Medical subject headings (MeSH) words included “stent thrombosis,” “percutaneous coronary intervention,” and “coronary stenting.” We extracted the research articles published between 2005 and 2021 on April 20, 2021. The included studies also focused on procedures and clinical factors concerning their association with PCI-related ST.

Our findings ruled out the progression of abnormal left ventricular ejection fraction (LVEF)-related stent thrombosis in PCI patients (odds ratio {OR}: 9.68, 95% CI: 1.88-49.90, p=0.007). We found an insignificant clinical correlation between stent thrombosis and PCI in the setting of acute coronary syndrome (ACS). Our study outcomes further revealed the absence of stent thrombosis in PCI patients with antiplatelet prescription (OR: 32.42, 95% CI: 21.28-49.39). The findings affirmed the absence of ST in PCI patients receiving aspirin therapy (OR: 32.77, 95% CI: 18.73-57.34; OR: 4.59, 95% CI: 1.97-10.73). The majority of the included studies negated the clinical correlation of stent thrombosis with diabetes mellitus in the setting of PCI (OR: 0.49, 95% CI: 0.06-3.78). Our study did not reveal statistically significant results based on stent thrombosis in PCI patients with drug-eluting stents (OR: 2.91, 95% CI: 0.35-24.49). The findings also did not reveal the impact of cardiac biomarker elevation on stent thrombosis in PCI patients (OR: 8.42, 95% CI: 2.54-27.98, p=0.0005). Eight studies revealed a statistically insignificant correlation between myocardial infarction and stent thrombosis in PCI scenarios (OR: 2.69, 95% CI: 0.89-8.11, p=0.08). The clinical correlation between PCI and stent thrombosis/major bleeding in the setting of hypertension also proved statistically insignificant at 0.67 (OR: 1.31, 95% CI: 0.38-4.51, p=0.97). The study findings did not correlate mean body mass index and multivessel coronary artery disease with ST in PCI scenarios (OR: 1.98, 95% CI: 0.02-239.58, p=0.78; OR: 1.09, 95% CI: 0.58-2.04, p=0.80). Only two studies revealed statistically significant results confirming stent thrombosis in PCI patients with a prior history of PCI (OR: 0.49, 95% CI: 0.23-1.06; OR: 0.33, 95% CI: 0.02-5.59; p=0.03).

Our findings question the clinical significance of baseline characteristics in terms of predicting stent thrombosis in PCI patients. The results support the requirement of future studies to investigate complex interactions between procedural, medicinal, genetic, and patient-related factors contributing to the development of stent thrombosis in PCI patients. 

Assessment of patients with a suspected cardioembolic ischemic stroke. A national consensus statement

OBJECTIVES

Several cardiovascular, structural, and functional abnormalities have been considered as potential causes of cardioembolic ischemic strokes. Beyond atrial fibrillation, other sources of embolism clearly exist and may warrant urgent action, but they are only a minor part of the many stroke mechanisms and strokes that seem to be of embolic origin remain without a determined source. The associations between stroke and findings like atrial fibrillation, valve calcification, or heart failure are confounded by co-existing risk factors for atherosclerosis and vascular disease. In addition, a patent foramen ovale which is a common abnormality in the general population is mostly an innocent bystander in patients with ischemic stroke. For these reasons, experts from the national Danish societies of cardiology, neurology, stroke, and neuroradiology sought to develop a consensus document to provide national recommendations on how to manage patients with a suspected cardioembolic stroke. Design: Comprehensive literature search and analyses were done by a panel of experts and presented at a consensus meeting. Evidence supporting each subject was vetted by open discussion and statements were adjusted thereafter. Results: The most common sources of embolic stroke were identified, and the statement provides advise on how neurologist can identify cases that need referral, and what is expected by the cardiologist. Conclusions: A primary neurological and neuroradiological assessment is mandatory and neurovascular specialists should manage the initiation of secondary prophylactic treatment. If a cardioembolic stroke is suspected, a dedicated cardiologist experienced in the management of cardioembolism should provide a tailored clinical and echocardiographic assessment.

Left Ventricular Thrombi: Insights from Cardiac Magnetic Resonance Imaging

Objective: Cardiovascular magnetic resonance imaging (CMR) late gadolinium enhancement technique (LGE) detects thrombus rather than anatomical presence based on tissue properties and is theoretically highly accurate. The present study’s goal was to compare the diagnostic accuracy obtained with various CMR techniques and transthoracic echocardiography to diagnose left ventricular thrombus and evaluate the prevalence and perspectives of left ventricular (LV) thrombus among patients with impaired systolic left ventricular function. Methods: In a single academic referral center, a retrospective database review of all CMR assessments of the established left ventricular thrombus was carried out in 206 consecutive patients with reduced systolic function for five years. To assess thrombus risk factors, clinical and imaging parameters were analyzed. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), echocardiography, and cine-CMR sequence accuracy have been identified. LV structural parameters were quantified to detect markers for thrombus and predictors of the additive usefulness of contrast-enhanced thrombus imaging. Comparisons against LGE-CMR were made, which was used as the standard. Results: A 7.8 percent prevalence of left ventricular thrombus was identified by LGE-CMR. Cine-CMR increased the diagnostic efficiency for echocardiographic thrombus identification in this group, with sensitivity increasing from 50 percent by echocardiography to 75 percent by cine-CMR (p = 0.008). Dark blood CMR (DB-CMR) has better sensitivity and accuracy than echocardiography (p < 0.001), comparable to cine-CMR. The transmural infarct size was an independent marker for thrombus after correction for the LVEF and LV volume while considering only CMR parameters. There were significantly higher embolic events (HR = 71.33; CI 8.31–616.06, p < 0.0001) in LV thrombus patients detected by LGE-CMR. Conclusion: CMR imaging was more sensitive to left ventricular thrombi identification compared with transthoracic echocardiography. An additional parameter available from LGE-CMR and shown as an independent risk factor for left ventricular thrombus is the myocardial scar.

Incidence and Predictors of Left Ventricular (LV) Thrombus after ST-Elevation Myocardial Infarction (STEMI) in the Holy Capital of Saudi Arabia

Background

Patients with acute myocardial infarction (AMI) especially those with large MI (myocardial infarction) as identified by ST elevation in multiple contiguous ECG leads or anterior MI, may suffer significant myocardial damage leading to impaired wall motion and contractility which may lead to the formation of left ventricular thrombus (LVT) in the patient. This study was aimed to establish the incidence of LV thrombus and determine the predictors associated with the formation of LV thrombus in patients with AMI.

Methods

This retrospective study was held at the only cardiothoracic centre of Makkah, which provides tertiary level cardiac services. A total of 3084 consecutive patients with acute MI between 2016 and 2019 were identified and divided into two groups i.e. group I (with LVT) and group II (without LVT). The case notes, echocardiography data and cardiac catheterization lab records were reviewed to identify patients with LV thrombus. Regression analysis was employed to evaluate the predictors responsible for the formation of LV thrombus.

Results

The overall incidence for LV thrombus was determined as 8.4% (n = 260/3084), while in the subpopulation of pilgrims, it was 8.2% (83/1001). Mean age for patients with and without LVT was 54 ± 11 years vs 56 ± 12 years (p < 0.003), respectively. There was no significant difference between the two groups with respect to gender, diabetes, hypertension, smoking, Arabic speaking or BMI>30. Coronary thrombus aspiration was utilized in 17% vs 12% (p < 0.023) patients with LVT and without LVT, respectively. It was observed that the patients with cardiac arrest tend to develop more LVT i.e. 8.5% vs 5.2% (p < 0.033). However, LV thrombus formation was significantly associated with anterior STEMI with incidence of LVT reaching 13.4% and low ejection fraction (all MI types) i-e. 32 ± 9% vs 42 ± 11%, with p < 0.000 for both independent predictors.

Conclusions

LV thrombus is a relatively common occurrence in patients with acute MI, especially those with anterior STEMI and low ejection fraction<30%. Appropriate imaging studies are required for all acute MI patients in order to ascertain the presence or absence of LV thrombus as it has major influence on further management.

Myocardial Infarction Complicated by Ischemic Stroke: Risk Factors, Prognosis, Unresolved Problems and Possible Methods of Prevention

The present work is devoted to the analysis of modern publications on various aspects of the development and course of ischemic stroke in the presence of acute myocardial infarction. A literature search was conducted on the websites of cardiological and neurological societies, as well as on the PubMed, EMBASE, eLibrary databases using the keywords: myocardial infarction, acute coronary syndrome, stroke, acute cerebrovascular accident, myocardial infarction, acute coronary syndrome, stroke. The authors of this review found that although stroke is a relatively rare complication of myocardial infarction, its prevention is an extremely significant task, since it is associated with high mortality, disability and a significant increase in the cost of treatment. So, it is extremely important to detect thrombosis of the left ventricular cavity in a timely manner, to register preexisting atrial fibrillation that occurs earlier or for the first time, followed by the appointment of anticoagulant therapy. Timely reperfusion treatment, the use of statins and modern dual antithrombotic therapy can reduce the risk of developing cerebrovascular accident in patients with myocardial infarction. It is likely that a decrease in the activity of subclinical inflammation after myocardial infarction will also reduce the risk of stroke, as was recently shown in the COLCOT study. Currently, it remains relevant to search for new knowledge about the risk factors for stroke, which complicated the course of myocardial infarction, which will allow developing more effective and personalized preventive measures in a patient with acute coronary syndrome.

Predictive utility of left heart catheterization indices for left ventricular thrombus formation after anterior ST-elevation myocardial infarction

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

AIM

To compare the safety and efficacy of direct oral anticoagulants (DOAC) relative to vitamin K antagonists (VKA) for the treatment of left ventricular thrombus (LVT).

METHODS

This retrospective study enrolled patients diagnosed with LVT from 2014-2017. Patient characteristics and outcomes within 12 months of LVT diagnosis were recorded and analyzed. A meta-analysis was also performed by pooling our results with existing data in literature.

RESULTS

14 DOAC and 59 VKA patients were included. Baseline demographic and clinical characteristics were similar except for age. Although more strokes within 12 months occurred in VKA (15%) than in DOAC (0%) patients, this was not statistically significant (P = 0.189). There were no significant differences in outcomes between patients on DOAC and VKA for acute coronary syndrome (ACS) (7%, vs 3.4%, P = .477), LVT resolution (86% vs 76%, P = .499) or bleeding (14% vs 14%, P = 1) within 12 months. The meta-analysis included 6 studies (n = 408 for DOACs; n = 1207 for VKA). There were no significant differences between DOACs versus VKAs with respect to odds for unresolved thrombus (OR 0.61, 95% CI 0.26,1.41), embolic events (OR 1.24, 95% CI 0.90,1.69), embolic events and death (OR 1.10, 95% CI 0.84,1.45) or bleeding events (OR 1.13, 95% CI 0.74,1.72).

CONCLUSIONS

Our study and meta-analysis suggest similar efficacy and safety of DOACs in the treatment of LVT compared to VKA. These findings underscore the need for a randomized controlled trial.

Value of the platelet-to-lymphocyte ratio in the prediction of left ventricular thrombus in anterior ST-elevation myocardial infarction with left ventricular dysfunction

Background

The predictors of left ventricular thrombus (LVT) formation are not well defined in the contemporary era, especially in those patients at high risk. We aimed to evaluate whether the platelet/lymphocyte ratio (PLR) is valuable in the determination of LVT formation in patients with anterior ST-elevation myocardial infarction (STEMI) and left ventricular (LV) dysfunction.

Methods

The LVT group (n = 46) was identified from anterior STEMI patients with LV dysfunction who were treated with primary percutaneous coronary intervention (PCI) from January 2017 to December 2019 at the China-Japan Union Hospital of Jilin University. The no-LVT group (n = 92) were also selected from the same batch of patients and were age- and sex-matched to the patients with LVT. The PLR was determined at admission and was calculated as the ratio of the platelet count to the lymphocyte count using the complete blood count. The presence of LVT was determined by echocardiography.

Results

The PLR were significantly higher in patients with LVT than in no-LVT group (p = 0.001). In a receiver operator characteristic curve (ROC) analysis, using a cut-off value of 118.07 (AUC 0.673, 95% CI: 0.574–0.771, P = 0.001), the PLR could independently predict the occurrence of LVT. Multivariate analysis showed that an increased PLR (OR = 1.011, 95% CI: 1.004–1.018, P = 0.002), the presence of a left ventricular aneurysm (OR = 46.350, 95% CI: 5.659–379.615, P < 0.001) and increased DTBT (OR = 1.005, 95% CI: 1.001–1.009, P = 0.012) were independent predictors of LVT formation.

Conclusions

In acute anterior STEMI patients with LV dysfunction, an increased PLR and DTBT and the presence of an LV aneurysm were independent predictors of LVT formation. A larger prospective study is warranted to evaluate this result.

Trial registration

This study was registered (May 4, 2019) on Chinese Clinical Trial Registry (ChiCTR-DDD-17011214).

Left Ventricular Thrombus Formation in Acute Anterior Wall Myocardial Infarction: A Comparison Between Thrombolyzed and Non-Thrombolyzed Patients

Introduction Left ventricular thrombus (LVT) formation is a prominent complication of acute myocardial infarction (AMI). Accurate and prompt detection of the condition is important as it poses a high risk for thromboembolic events that can be arrested by systemic anticoagulation. The purpose of our study was to evaluate the frequency of LVT formation in thrombolyzed and non-thrombolyzed patients with AMI to ascertain the current magnitude of the problem in the local population. Methods The study was conducted at the Chaudhry Pervaiz Elahi Institute of Cardiology in Multan, Pakistan. A total of 281 patients of either gender aged between 30-65 years with anterior wall myocardial infarction (AWMI; both thrombolyzed and non-thrombolyzed) were included in the study. Once they were enrolled in the study, all the relevant baseline investigations were performed. A detailed history was taken and examinations were done; serial ECG and echocardiography were performed till discharge from the hospital on the third day of hospitalization to record the final outcome of the study, i.e., LVT formation. Results The mean age of the patients was 55.54 ± 7.26 years. Overall, LVT formation was noted in 65 cases (23.1%), of which 11 (16.9%) were thrombolyzed patients and 54 (83.1.1%) were non-thrombolyzed. A significant association of LVT was noted with age, hypertension, family history, and duration of symptoms. Conclusion We found a high frequency of LVT formation among patients with AWMI who have not undergone thrombolytic therapy. It was observed that LVT was notably associated with advanced age, hypertension, and other comorbidities. Early presentation to the hospital and thrombolysis reduce the risk of developing LVT, which in turn can reduce morbidity and mortality in such patients.

Left ventricular thrombosis: new perspectives on an old problem

Left ventricular thrombosis (LVT) is a major risk factor for systemic thromboembolism and might complicate both the acute and the chronic phase of ischaemic heart disease after myocardial infarction and, less frequently, non-ischaemic cardiomyopathies. The pathophysiology of thrombus formation is complex and involves the three aspects of Virchow's triad: blood stasis, prothrombotic state, and tissue injury. Advances in technology have improved the detection rate of intracardiac thrombi, but several uncertainties still remain regarding the optimal treatment strategy within daily clinical practice. Of note, anticoagulation therapy with heparin and vitamin K antagonists decreases the risk of embolic stroke though exposing patients to an undeniable risk of bleeding complications. Although limited data on the off-label use of direct oral anticoagulants have reported safety and efficacy for LVT resolution, yet more evidence is needed to justify their use in clinical practice.

Peripheral Embolization of Left Ventricular Thrombus Leading to Acute Bilateral Critical Limb Ischemia: A Rare Phenomenon

Left ventricular thrombus (LVT) is a well-known complication of myocardial infarction (MI) leading to significant morbidity and mortality. LVT can also lead to systemic thromboembolic events causing threatening limb ischemia. We report a rare case of critical bilateral limb ischemia that resulted from peripheral embolization of LVT post MI, which was managed successfully by emergent surgical intervention and anticoagulation. A 74-year-old male with a medical history of hypertension, diabetes, hyperlipidemia and coronary artery disease status post stenting of the left anterior descending and left circumflex arteries presented to the emergency department with typical chest pain and progressive shortness of breath. Cardiac troponin levels on admission were 35 ng/mL of blood. The patient subsequently underwent emergent cardiac catheterization which revealed significant triple vessel disease, and was referred for coronary artery bypass grafting (CABG) surgery. Transthoracic and transesophageal echocardiograms revealed the presence of an apical aneurysm with chronic organized mobile thrombus at the apex. Post CABG, the patient complained of excruciating right leg pain. Computed tomography (CT) angiogram of the abdominal aorta and lower extremities revealed a large embolus at the aortic bifurcation occluding the right and nearly occluding the left common iliac arteries and thrombus in the right popliteal artery. He underwent emergent vascular surgery with resolution of his symptoms and remained without further complications. The incidence of LVT remains high in post-MI patients, and complications of LVT are known to include thromboembolic events. Peripheral embolization of acute or chronic LVT leading to bilateral distal embolization and critical limb ischemia remains a rare occurrence. This case report aims to aid clinicians to recognize and promptly manage LVT and related arterial thromboembolic events with anticoagulation and emergent surgical intervention if limb ischemia develops.

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

Background

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

Methods

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

Results

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

Conclusion

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

Catastrophic Intracardiac Thrombosis During Emergency Repair of an Expanding Aortic Pseudoaneurysm: A Case Report

Catastrophic thrombosis is a rare but frequently fatal event following complex cardiac surgery. It is most often encountered following separation from cardiopulmonary bypass (CPB) and reversal of heparin anticoagulation, and somewhat paradoxically, at the time when bleeding from post-CPB coagulopathy is being treated. We report the case of a 41-year-old female taken to the operating room for repair of an expanding ascending aortic pseudoaneurysm. Following a prolonged operation, she developed intracardiac thrombus during transfusion of hemostatic blood products and procoagulant agents. Potential contributing factors are discussed.

In-hospital left ventricular thrombus following ST-elevation myocardial infarction

BACKGROUND

In-hospital left ventricular (LV) thrombus following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale and was the focus of this investigation.

METHODS

We used the 2003 to 2013 Nationwide Inpatient Sample database to identify adults ≥18 years old with a principal diagnosis code of ST-elevation myocardial infarction. Patients were divided into two groups defined by the presence or absence of LV thrombus. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models were conducted to identify factors associated with LV thrombus.

RESULTS

Of 1,035,888 STEMI patients hospitalized in the U. S from 2003 to 2013, 1982 (0.2%) developed acute in-hospital LV thrombus. Compared to no LV thrombus, patients with LV thrombus were more likely to have in-hospital complications; acute ischemic and hemorrhagic stroke, acute renal failure, gastrointestinal bleed, cardiogenic shock, in-hospital cardiac arrest and mortality. They also had longer mean length of stay and higher hospital charges. Factors associated with LV thrombus included: anterior/anterolateral STEMI, acute or chronic heart failure with reduced ejection fraction, atrial fibrillation, LV aneurysm, Left heart valvular disease, acute or chronic deep venous thrombosis/pulmonary embolism and alcohol abuse. Patients with LV thrombus were less likely to be female [AOR 0.66, 95% CI (0.51-0.84)].

CONCLUSION

The identification of factors associated with early development of LV thrombus following STEMI, will help direct resources for specific high-risk group and prompt cost-effective therapies. Gender variability in LV thrombus development warrants further investigations.

Post-ischaemic exuberant left ventricular mass: thrombus vs. tumour-case report

Background

We present a case that illustrates the diagnostic challenge of differentiating thrombus from tumour when confronted with a large left ventricular (LV) cardiac mass.

Case Summary

A 43-year-old Caucasian woman polysubstance-abuser presented to a regional hospital with an ST-elevation myocardial infarction and underwent aspiration-thrombectomy and successful circumflex artery bare metal stenting. She was noted to have an exuberant LV mass on transthoracic echocardiogram the following day and transferred to our care. Transthoracic echocardiogram, transoesophageal echocardiogram, and cardiac magnetic resonance imaging were performed in an attempt to characterize the mass with conflicting findings for either thrombus or tumour. The mass was surgically excised and final pathology indicated a fibrin-rich thrombus.

Discussion

The association of the mass with an infarcted area of the left ventricle supported the diagnosis of thrombus. However, due to the size and some imaging features a myxoma could not be completely ruled out. Atypical presentations of thrombus can be difficult to differentiate from cardiac tumours.

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

AIM

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

METHOD

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

RESULT

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

CONCLUSION

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

Use of direct oral anticoagulants in the treatment of left ventricular thrombi: A tertiary center experience and review of the literature

Direct oral anticoagulants can potentially provide a more convenient oral alternative for the management of left ventricular thrombi than Warfarin. These medications do not require frequent monitoring and have less drug-drug interactions. Randomized controlled trials are needed to further demonstrate their efficacy and safety in this setting.

Predictors and prognosis of left ventricular thrombus in post-myocardial infarction patients with left ventricular dysfunction after percutaneous coronary intervention

Background

We aimed to investigate the predictors and prognosis of left ventricular thrombus (LVT) in patients admitted for post-myocardial infarction (MI) and left ventricular dysfunction after contemporary percutaneous coronary intervention (PCI).

Methods

We prospectively enrolled 267 consecutive post-MI patients with left ventricular ejection fraction (LVEF) <0.45 based on the Shanghai East Hospital PCI database since 2012. Altogether 25 (9.36%) patients were selected as the LVT group. Baseline, angiographic, procedural characteristics and 1-year clinical outcomes were compared by Chi-square test, t-test or Kaplan-Meier survival analysis as appropriate. Receiver operating characteristic (ROC) curves were plotted for the accuracy of the multivariate analysis model. A multiple logistic regression was applied to predict LVT formation.

Results

The independent risk factors of LVT were left ventricular aneurysm [odds ratio (OR): 1.29, 95% confidence interval (CI): 1.09-1.52, P<0.01], incomplete revascularization (OR: 0.05, 95% CI: 0.01-0.35, P<0.01), SYNTAX score (OR: 1.28, 95% CI: 1.14-1.43, P<0.01) and D-dimer (OR: 1.90, 95% CI: 1.19-3.04, P<0.01). The SYNTAX score and D-dimer effectively indicated the development of LVT with optimal cutoff values of 29.50 and 1.53 mg/L, respectively. Patients with LVT had significantly worse outcomes at 1-year clinical follow-up, especially higher incidence of ischemic or hemorrhagic stroke.

Conclusions

This study indicated that the presence of left ventricular aneurysm, incomplete revascularization, higher SYNTAX score and D-dimer level were the independent predictors of LVT formation in post-MI and LV dysfunction patients, which related to worse clinical outcomes. Future studies for early intervention and complete revascularization in high-risk subgroup patients are expected.

Comparison of Systematic Ticagrelor-Based Dual Antiplatelet Therapy to Selective Triple Antithrombotic Therapy for Left Ventricle Dysfunction Following Anterior STEMI

Antithrombotic management of STEMI patients with apical dysfunction, but without demonstrable thrombus, is controversial. Triple antithrombotic therapy (TATT, defined as the addition of oral anticoagulation to dual antiplatelet therapy, or DAPT) may be associated with increased bleeding, while DAPT alone may not adequately protect against cardio-embolic events. We undertook a dual-center study of anterior STEMI patients treated with primary PCI (pPCI) from 2013 to 2015 and presenting presumed new apical dysfunction. The Centre hospitalier de l'Université de Montréal (CHUM) uses a strategy of selective TATT, whereas the Centre hospitalier universitaire de Sherbrooke (CHUS) has favored ticagrelor-based DAPT for all patients since 2013. The primary composite outcome consisted of death, MI, stroke, revascularization, and BARC 3 to 5 bleeding up to 4-months follow-up. We identified 177 cases (69 CHUM; 108 CHUS). Baseline characteristics were similar and procedural success was high (97%). There was no difference in post-procedure LVEF (39 ± 9% vs 37 ± 9%) or the extent of apical dysfunction. The primary composite outcome occurred in 27% with the selective TATT strategy compared to 19% with ticagrelor-DAPT (p = 0.342). Thus, this retrospective dual-center analysis does not support a strategy of conventional TATT over ticagrelor-based DAPT for patients with apical dysfunction following anterior STEMI treated with pPCI. A pragmatic randomized trial is needed to provide a definitive answer to this clinical conundrum.

Prevention of Left Ventricular Thrombus Formation and Systemic Embolism After Anterior Myocardial Infarction: A Systematic Literature Review

BACKGROUND

Anterior myocardial infarction (MI) with apical dysfunction is associated with an increased risk of left ventricular thrombus (LVT) formation and systemic embolism (SE). However, the role for prophylactic anticoagulation in current practice is a matter of debate.

METHODS

We conducted a systematic review of peer-reviewed original articles in either English or French on the benefit of combining anticoagulation with standard therapy for the prevention of LVT/SE after MI by searching PubMed, Ovid/MedLine/Embase, the Cochrane Library, and Google Scholar.

RESULTS

Of 7382 identified records, 14 were retained for analysis. Nine articles addressed anticoagulation for patients not treated with percutaneous coronary intervention (PCI). Another 5 included at least some patients treated with PCI. Only 1 study specifically addressed exclusively a primary PCI population. Some studies showed a benefit for combining anticoagulation with standard therapy in patients not treated with PCI, but results were inconsistent. No evidence of benefit was reported when PCI patients were included and 1 study reported a signal for net harm. There was important interstudy heterogeneity and methodological limitations. Studies were likely individually underpowered.

CONCLUSIONS

The available studies of LVT/SE prevention after MI lacked statistical power and are heterogeneous in terms of treatments, revascularization methods, background medical therapy, and study design. We conclude that there is presently no compelling evidence for or against combining anticoagulation with standard therapy for post-MI patients with apical dysfunction after primary PCI, and inconsistent evidence supporting prophylaxis after thrombolysis. An appropriately powered randomized trial is required to answer this clinically relevant question.

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

Background

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

Methods and Results

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

Conclusions

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