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Correia JL, Ferreira GRM, Fiuza JG, Almeida MD, Coelho J, Correia E, Correia JM, Moreira D, Craveiro N, Gonçalves ML, Neto VD. Left ventricular thrombus routine screening with contrast echocardiography in patients with anterior ST-elevation myocardial infarction: is it worth it? J Cardiovasc Imaging 2024; 32:21. [PMID: 39103940 PMCID: PMC11299253 DOI: 10.1186/s44348-024-00027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/07/2023] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Left ventricular (LV) thrombus has a higher incidence among patients with anterior ST-elevation myocardial infarction (STEMI) when compared to other types of acute myocardial infarction and is associated with worse prognosis. The management of LV thrombus diagnosis remains challenging. Contrast echocardiography (transthoracic echocardiography, TTE) has shown potential in improving the accuracy for its diagnosis, thereby influencing treatment strategies concerning antithrombotic/anticoagulation therapy. The aim of this study was to assess the effectiveness of contrast TTE as a routine screening method for detecting LV thrombus in the acute phase of anterior STEMI. METHODS A prospective, single center, randomized controlled trial was conducted among patients with anterior STEMI. The study group underwent contrast TTE, while the control group received a conventional approach. Demographical, clinical, and diagnostic data were collected. Thrombus detection rates were compared between groups. RESULTS A total of 68 patients were included (32 in the study group and 36 in the control group). No substantial baseline differences were observed between groups. Thrombus detection rate was 25.0% in the study group and 13.9% in the control group, however these results did not reach statistical significance (P = 0.24). The prevalence of anterior/apical aneurysm was higher in the study group (46.9% vs. 22.2%, P = 0.03). CONCLUSIONS Conventional TTE may be adequate for diagnosing LV thrombus in the acute phase of anterior STEMI; however, further larger-scale and multicenter studies are necessary to obtain more robust and conclusive results. Ultrasound contrast may play a significant role in the detection of anterior/apical aneurysms, which are known risk factors for the subsequent development of thrombus. TRIAL REGISTRATION NCT06480929 (ClinicalTrials.gov, Retrospectively registered).
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Affiliation(s)
| | | | | | | | - Joana Coelho
- Internal Medicine Department, Centro Hospitalar Universitário Cova da Beira, Covilhã, Portugal
| | - Emanuel Correia
- Cardiology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | | | - Davide Moreira
- Cardiology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Nuno Craveiro
- Cardiology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | | | - Vanda Devesa Neto
- Cardiology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
- Universidade da Beira Interior, Covilhã, Portugal
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2
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Chen X, Zhang X, Yang Y, Sun Y, Si J, Jiang S, Hu Y, Ding Z, Xia Y, Chen Y, Liu Y. Left ventricular reverse remodelling as a promising strategy for resolving left ventricular thrombus. ESC Heart Fail 2024; 11:2214-2222. [PMID: 38628024 PMCID: PMC11287347 DOI: 10.1002/ehf2.14781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/27/2023] [Accepted: 03/15/2024] [Indexed: 07/31/2024] Open
Abstract
AIMS Recent years, several studies have suggested that abnormal baseline left ventricular (LV) function and structure are associated with left ventricular thrombus (LVT) formation. Despite this, most studies have given less attention to the potential role of left ventricular reverse remodelling (LVRR), that is, the improvement of LV function and structure, in resolving LVT. In this study, we aim to investigate the clinical characteristics, prognosis, and LVT resolution in patients with LVRR. METHODS AND RESULTS This is a retrospective study conducted at The First Affiliated Hospital of Dalian Medical University. Our cohort consists of patients diagnosed with LVT between 1 November 2015 and 31 May 2020. Enrolled patients were categorized into two groups: LVRR and Failure of LVRR. The primary endpoints included LVT resolution and embolic events. A total of 84 patients were included in the study, with 59 patients in the LVRR group and 25 patients in the Failure of LVRR group. In our study, patients in the LVRR group experienced higher incidence of LVT resolution and a lower risk of embolic events. Multivariate logistic analysis revealed that Failure of LVRR was the only independent negative predictor for LVT resolution and positive predictor for embolic events. CONCLUSIONS Patients with LVRR experience higher incidence of LVT resolution and have lower risk of embolic events, highlighting the significance of identifying and mitigating risk factors that contribute to abnormal LV function and structure in management of patients with LVT.
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Affiliation(s)
- Xuefu Chen
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Xinxin Zhang
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Yahui Yang
- College of PharmacyDalian Medical UniversityDalianChina
- School of Pharmaceutical SciencesShandong UniversityJinanChina
| | - Yuxi Sun
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
- Department of Cardiology, West China HospitalSichuan UniversityChenduChina
| | - Jinping Si
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Shufen Jiang
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Yuze Hu
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Zijie Ding
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Yunlong Xia
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Yanwei Chen
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Ying Liu
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
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3
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Ichikawa S, Mochizuki Y, Miyazaki H, Hachiya R, Toyosaki E, Fukuoka H, Shinke T. Dramatic changes before and after anticoagulation for giant thrombus in the left ventricle complicated by nonischemic cardiomyopathy. J Echocardiogr 2024; 22:102-103. [PMID: 37368232 DOI: 10.1007/s12574-023-00610-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/08/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Saaya Ichikawa
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-Ku, Tokyo, 142-8555, Japan.
| | - Haruka Miyazaki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Rumi Hachiya
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Eiji Toyosaki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Hiroto Fukuoka
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-Ku, Tokyo, 142-8555, Japan
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4
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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 2024; 38:483-492. [PMID: 36538031 DOI: 10.1007/s10557-022-07417-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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Vorla M, Kalra DK. Meta-Analysis of the Safety and Efficacy of Direct Oral Anticoagulants for the Treatment of Left Ventricular Thrombus. Pharmaceuticals (Basel) 2024; 17:708. [PMID: 38931375 PMCID: PMC11206604 DOI: 10.3390/ph17060708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/25/2024] [Accepted: 05/26/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Literature on the preferred anticoagulant for treating left ventricular thrombus (LVT) is lacking. Thus, our objective was to compare the efficacy of DOACs versus warfarin in treating LVT. METHODS Databases were searched for RCTs and adjusted observational studies that compared DOAC versus warfarin through March 2024. The primary efficacy outcomes of interest were LVT resolution, systemic embolism, composite of stroke, and TIA. The primary safety outcomes encompassed all-cause mortality and bleeding events. RESULTS Our meta-analysis including 31 studies demonstrated that DOAC use was associated with higher odds of thrombus resolution (OR: 1.08, 95% CI: 0.86-1.31, p: 0.46). A statistically significant reduction in the risk of stroke/TIA was observed in the DOAC group versus the warfarin group (OR: 0.65, 95% CI: 0.48-0.89, p: 0.007). Furthermore, statistically significant reduced risks of all-cause mortality (OR: 0.68, 95% CI: 0.47-0.98, p: 0.04) and bleeding events (OR: 0.70, 95% CI: 0.55-0.89, p: 0.004) were observed with DOAC use as compared to warfarin use. CONCLUSION Compared to VKAs, DOACs are noninferior as the anticoagulant of choice for LVT treatment. However, further studies are warranted to confirm these findings.
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Affiliation(s)
- Mounica Vorla
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL 61822, USA;
| | - Dinesh K. Kalra
- Division of Cardiology, University of Louisville, Louisville, KY 40292, USA
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6
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Fan M, Tang L, Song H, Wang Y. Foramen ovale thrombus found during the implantation of extracorporeal left ventricular assist device. Asian J Surg 2024; 47:2230-2232. [PMID: 38309999 DOI: 10.1016/j.asjsur.2024.01.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/19/2024] [Indexed: 02/05/2024] Open
Affiliation(s)
- MinMin Fan
- Department of Anesthesiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, China
| | - Li Tang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Haibo Song
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - YanYan Wang
- Nursing Key Laboratory of Sichuan Province, National Clinical Research Center for Geriatrics, and Science and Technology Department, West China Hospital, Sichuan University, Chengdu, China.
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Colle B, Demeure F, Higny J, Benoit M, Henry JP, Michaux I, Robaye B, Xhaët O, Gabriel L, Guedes A, Blommaert D, Dulieu N, Berners Y, Wery F, Droogmans S, Cosyns B, Luchian ML. Emerging Trends in Left Ventricular Thrombus: A Comprehensive Review of Non-Ischemic and Ischemic Cardiopathies, Including Eosinophilic Myocarditis, Chagas Cardiomyopathy, Amyloidosis, and Innovative Anticoagulant Approaches. Diagnostics (Basel) 2024; 14:948. [PMID: 38732361 PMCID: PMC11083388 DOI: 10.3390/diagnostics14090948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
This comprehensive review explores the intricate aspects of left ventricular thrombus (LVT), a potential complication in both ischemic and non-ischemic cardiomyopathies. It provides a thorough understanding of left ventricular thrombus, revealing its uncommon incidence in the general population (7 cases per 10,000 patients), predominantly linked to ischemic heart diseases (ICMs) at an 80% prevalence rate. Diagnostic tools, notably transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR), demonstrate varying sensitivity but remain indispensable in specific clinical contexts related to LVT as non-invasive diagnostic modalities. A detailed comparison between ICM patients and those with non-ischemic cardiomyopathy (NICM) who have left ventricular thrombus reveals subtle distinctions with significant clinical implications. This analysis underscores the importance of these imaging techniques in distinguishing between the two conditions. Additionally, we explored the occurrence of LVT in specific non-ischemic cardiomyopathies, including Takotsubo syndrome, hypertrophic cardiomyopathy, eosinophilic myocarditis, Chagas disease, cardiac amyloidosis, and several other conditions. The article further delves into anticoagulation strategies, thoroughly examining their impact on LVT regression and patient outcomes. Pharmacological interventions, with a focus on direct oral anticoagulants, emerge as promising alternatives; however, there is insufficient information on their efficiency and safety, especially in NICM population. In conclusion, this review highlights the complex nature of LVT, incorporating a range of etiopathogenic factors, diagnostic complexities, and evolving therapeutic approaches. It emphasizes the pressing need for ongoing research in this field.
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Affiliation(s)
- Benjamin Colle
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Fabian Demeure
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Julien Higny
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Martin Benoit
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Jean-Philippe Henry
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Isabelle Michaux
- Department of Intensive Care, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Benoit Robaye
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Olivier Xhaët
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Laurence Gabriel
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Antoine Guedes
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Dominique Blommaert
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Nathalie Dulieu
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Yannick Berners
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Fabian Wery
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
| | - Steven Droogmans
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Bernard Cosyns
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Maria-Luiza Luchian
- Department of Cardiology, Université Catholique de Louvain (UCL), CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium
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Bundrick AE, Bowers RD, Perkins SL, Baker CN. Reduced-Dose Apixaban in the Treatment of Left Ventricular Thrombus: A Report of 2 Cases. J Pharm Pract 2024; 37:517-521. [PMID: 36475939 DOI: 10.1177/08971900221145051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
According to the American College of Cardiology and the American Heart Association, warfarin has historically been the standard of care anticoagulant for the treatment of left ventricular thrombus. The use of direct oral anticoagulants (DOACs) has become more prevalent, as they require less frequent laboratory monitoring, offer fixed-dose regimens, are associated with fewer drug-drug and drug-food interactions, and provide more favorable safety profiles when compared to warfarin. However, DOACs are not currently FDA-indicated in the treatment of left ventricular (LV) thrombus. Numerous recent studies have reported and evaluated the use of DOACs for treatment of LV thrombus. Recently, a prospective, open-label, multicenter study evaluated warfarin compared to DOACs for LV thrombus treatment. The AHA recently published a scientific statement regarding the management of patients at risk for and with left ventricular thrombus, which included DOACs as a reasonable alternative to warfarin. This report describes two patients treated with DOACs following LV thrombus diagnosis. The first case is a 71-year-old male admitted for cerebrovascular accident and non-ST-elevation myocardial infarction complicated by a LV thrombus. The second case is an 83-year-old female admitted for acute myocardial infarction complicated with an LV thrombus. Both patients were prescribed apixaban 2.5 mg twice daily. Neither patient has experienced LV thrombus or DOAC treatment related complications. This case series serves as evidence for reduced-dose DOACs as an alternative to warfarin in the treatment of LV thrombus.
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Affiliation(s)
- Adrienne E Bundrick
- Cape Fear Valley Medical Center, Medical University of South Carolina, Fayetteville, NC, USA
| | - Riley D Bowers
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - Scott L Perkins
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
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Kodama Y, Matsumoto K, Kubota H, Furuya O, Kawase Y. A case report of concurrent management of acute myocardial infarction complicated by left ventricular thrombus and ischaemic stroke. Eur Heart J Case Rep 2024; 8:ytae193. [PMID: 38680827 PMCID: PMC11050652 DOI: 10.1093/ehjcr/ytae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 05/01/2024]
Abstract
Background Left ventricular thrombus (LVT) formation is a serious complication of acute myocardial infarction (AMI) requiring complicated management strategies and collaboration among cardiologists, cardiovascular surgeons, and neurosurgeons. Case summary We present the case of an 83-year-old female patient with AMI. Emergency coronary angiography revealed subtotal occlusion of the proximal left anterior descending artery, and the patient was successfully treated with a drug-eluting stent. The following day, she suddenly developed loss of consciousness, global aphasia, and right hemiplegia. Brain magnetic resonance imaging revealed acute ischaemic cerebral infarction caused by multiple mobile LVT, as demonstrated by echocardiography. After a heart-brain team discussion, we decided to perform percutaneous mechanical thrombectomy. Successful recanalization was achieved with mechanical thrombectomy 2 h after presentation, which resulted in significant neurological recovery. Immediately after the thrombectomy, she was transferred to a cardiovascular surgery centre for surgical removal of multiple LV apical thrombi. Two weeks after the operation, the patient was discharged with the recovery of LV systolic function. Discussion Although AMI complicated by acute stroke caused by LVT remains a clinical challenge, a multidisciplinary approach is critically important for optimal care. Based on an urgent team discussion, we decided to perform endovascular thrombectomy for ischaemic stroke, followed by surgical removal of the LVT, requiring patient transportation to the cardiovascular surgery centre. Given that the heart and brain team-based approach remains confined to large, specialized centres, it might be beneficial to establish a community-based integrated heart-brain team that can address the growing needs of complex patients.
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Affiliation(s)
- Yuka Kodama
- Department of Cardiology, Izumi City General Hospital, 4-5-1 Wake-cho, Izumi 594-0073, Japan
| | - Kenji Matsumoto
- Department of Cardiology, Izumi City General Hospital, 4-5-1 Wake-cho, Izumi 594-0073, Japan
| | - Hisashi Kubota
- Department of Neurosurgery, Kubota Clinic Neurosurgery, Izumi, Japan
| | - Onichi Furuya
- Department of Cardiovascular Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Yoshio Kawase
- Department of Cardiology, Izumi City General Hospital, 4-5-1 Wake-cho, Izumi 594-0073, Japan
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Fardman A, Massalha E, Natanzon SS, Brodov Y, Goitein O, Chernomordik F, Herscovici R, Grupper A, Kuperstein R, Mazin I, Matetzky S, Beigel R. Clinical predictors of left ventricular thrombus after myocardial infarction as detected by magnetic resonance imaging. Front Cardiovasc Med 2024; 10:1275390. [PMID: 38292454 PMCID: PMC10824980 DOI: 10.3389/fcvm.2023.1275390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/29/2023] [Indexed: 02/01/2024] Open
Abstract
Background The diagnosis of a left ventricular (LV) thrombus in patients with ST-segment elevation myocardial infarction (STEMI) remains challenging. The aim of the current study is to characterize clinical predictors for LV thrombus formation, as detected by cardiac magnetic resonance imaging (CMRI). Methods We retrospectively evaluated 337 consecutive STEMI patients. All patients underwent transthoracic echocardiography (TTE) and CMRI during their index hospitalization. We developed a novel risk stratification model (ThrombScore) to identify patients at risk of developing an LV thrombus. Results CMRI revealed the presence of LV thrombus in 34 patients (10%), of whom 33 (97%) had experienced an anterior wall myocardial infarction (MI), and the majority (77%) had at least mildly reduced left ventricular ejection fraction (LVEF < 45%). The sensitivity for thrombus formation of the first and second TTE was 5.9% and 59%, respectively. Multivariate logistic regression model revealed that elevated C-reactive protein levels, lack of ST-segment elevation (STe) resolution, elevated creatine phosphokinase levels, and STe in anterior ECG leads are robust independent predictors for developing an LV thrombus. These variables were incorporated to construct the ThrombScore: a simple six-point risk model. The odds ratio for developing thrombus per one-point increase in the score was 3.2 (95% CI 2.1-5.01; p < 0.001). The discrimination analysis of the model revealed a c-statistic of 0.86 for thrombus development. The model identified three distinct categories (I, II, and III) with corresponding thrombus incidences of 0%, 1.6%, and 27.6%, respectively. Conclusion ThrombScore is a simple and practical clinical model for risk stratification of thrombus formation in patients with STEMI.
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Affiliation(s)
- Alexander Fardman
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eias Massalha
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | - Yafim Brodov
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Orly Goitein
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Fernando Chernomordik
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Romana Herscovici
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Avishay Grupper
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Rafael Kuperstein
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Israel Mazin
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Roy Beigel
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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11
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Li XL, Adi D, Wu Y, Aizezi A, Li YP, Kerem M, Wei X, Liu F, Ma X, Ma YT. A nomogram to predict ventricular thrombus in dilated cardiomyopathy patients. J Thromb Thrombolysis 2024; 57:29-38. [PMID: 37351822 PMCID: PMC10830674 DOI: 10.1007/s11239-023-02846-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND VT (Ventricular Thrombus) is a serious complication of dilated cardiomyopathy (DCM). Our goal is to develop a nomogram for personalized prediction of incident VT in DCM patients. METHODS 1267 patients (52.87 ± 11.75 years old, 73.8% male) were analyzed retrospectively from January 01, 2015, to December 31, 2020. A nomogram model for VT risk assessment was established using minimum absolute contraction and selection operator (LASSO) and multivariate logistic regression analysis, and its effectiveness was validated by internal guidance. The model was evaluated by the area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis (DCA). We compared the performance in predicting VT between nomogram and CHA2DS2, CHA2DS2- VASc or ATRIA by AUC, akaike information criterion (AIC), bayesian information criterion (BIC), net reclassification index (NRI), and integrated discrimination index (IDI). RESULTS 89 patients (7.02%) experienced VT. Multivariate logistic regression analysis revealed that age, left ventricular ejection fraction (LVEF), uric acid (UA), N-terminal precursor B-type diuretic peptide (NT-proBNP), and D-dimer (DD) were important independent predictors of VT. The nomogram model correctly separates patients with and without VT, with an optimistic C score of 0.92 (95%CI: 0.90-0.94) and good calibration (Hosmer-Lemeshow χ2 = 11.51, P = 0.12). Our model showed improved prediction of VT compared to CHA2DS2, CHA2DS2-VASc or ATRIA (all P < 0.05). CONCLUSIONS The novel nomogram demonstrated better than presenting scores and showed an improvement in predicting VT in DCM patients.
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Affiliation(s)
- Xiao-Lei Li
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Dilare Adi
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Yun Wu
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of General Medicine, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, China
| | - Aibibanmu Aizezi
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Yan-Peng Li
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Munawar Kerem
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Xian Wei
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Fen Liu
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Xiang Ma
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
| | - Yi-Tong Ma
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
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Liu Y, Wang T, Zhou Q, Xin G, Niu H, Li F, Wang Y, Li S, Dong Y, Zhang K, Feng L, Fu W, Zhang B, Huang W. Endogenous SIRT6 in platelets negatively regulates platelet activation and thrombosis. Front Pharmacol 2023; 14:1268708. [PMID: 38186648 PMCID: PMC10766690 DOI: 10.3389/fphar.2023.1268708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Thromboembolism resulting from platelet dysfunction constitutes a significant contributor to the development of cardiovascular disease. Sirtuin 6 (SIRT6), an essential NAD+-dependent enzyme, has been linked to arterial thrombosis when absent in endothelial cells. In the present study, we have confirmed the presence of SIRT6 protein in anucleated platelets. However, the precise regulatory role of platelet endogenous SIRT6 in platelet activation and thrombotic processes has remained uncertain. Herein, we present compelling evidence demonstrating that platelets isolated from SIRT6-knockout mice (SIRT6-/-) exhibit a notable augmentation in thrombin-induced platelet activation, aggregation, and clot retraction. In contrast, activation of SIRT6 through specific agonist treatment (UBCS039) confers a pronounced protective effect on platelet activation and arterial thrombosis. Moreover, in platelet adoptive transfer experiments between wild-type (WT) and SIRT6-/- mice, the loss of SIRT6 in platelets significantly prolongs the mean thrombus occlusion time in a FeCl3-induced arterial thrombosis mouse model. Mechanistically, we have identified that SIRT6 deficiency in platelets leads to the enhanced expression and release of proprotein convertase subtilisin/kexin type 9 (PCSK9), subsequently activating the platelet activation-associated mitogen-activated protein kinase (MAPK) signaling pathway. These findings collectively unveil a novel protective role of platelet endogenous SIRT6 in platelet activation and thrombosis. This protective effect is, at least in part, attributed to the inhibition of platelet PCSK9 secretion and mitogen-activated protein kinase signaling transduction. Our study provides valuable insights into the intricate interplay between SIRT6 and platelet function, shedding light on potential therapeutic avenues for managing thrombotic disorders.
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Affiliation(s)
- Yanli Liu
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Wang
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qilong Zhou
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Guang Xin
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hai Niu
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fan Li
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yilan Wang
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Shiyi Li
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yuman Dong
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Kun Zhang
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lijuan Feng
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Fu
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Boli Zhang
- Innovative Chinese Medicine Academician Workstation, West China Hospital, Sichuan University, Chengdu, China
| | - Wen Huang
- Department of Neurosurgery, Laboratory of Ethnopharmacology, Tissue-orientated Property of Chinese Medicine Key Laboratory of Sichuan Province, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
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13
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Fonseca AC. Stroke and Recent Myocardial Infarction, Reduced Left Ventricular Ejection Fraction, Left Ventricular Thrombus, and Wall Motion Abnormalities. Curr Cardiol Rep 2023; 25:1687-1697. [PMID: 38079058 PMCID: PMC10810933 DOI: 10.1007/s11886-023-02009-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE OF REVIEW To review the evidence regarding stroke and recent myocardial infarction (MI), reduced left ventricular ejection fraction, left ventricular thrombus (LVT), and wall motion abnormalities (WMA). RECENT FINDINGS The risk of ischemic stroke associated with acute MI has been greatly reduced with reperfusion treatments that improved myocardium salvage. Acute ischemic stroke is an uncommon complication of diagnostic coronary angiography and percutaneous coronary intervention. For established LVT, anticoagulation is superior to antiplatelet medications to reduce the risk of ischemic stroke. The duration of anticoagulation should be at least 3 to 6 months. Direct oral anticoagulants have been used off-label in this context. In patients with low ejection fraction or WMA, there is no evidence that anticoagulation is superior to antiplatelet treatment in preventing ischemic stroke. In patients with ischemic stroke and recent MI (< 3 months), type of MI (STEMI or NSTEMI), timing, and location should be considered when deciding whether intravenous thrombolysis should be used for stroke treatment. Mechanical thrombectomy should be considered as a therapeutic alternative to intravenous thrombolysis in patients with acute ischemic stroke due to large-vessel occlusion and recent MI. Most guidelines regarding prevention of ischemic stroke in patients with these cardiac causes of stroke are derived from expert opinion. There is a need for high quality evidence to support stroke prevention treatments in these patients.
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Affiliation(s)
- Ana Catarina Fonseca
- Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Avenida Professor Egas Moniz, 1640-035, Lisboa, Portugal.
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
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14
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Almajed MR, Almajed A, Khan N, Obri MS, Ananthasubramaniam K. Systemic right ventricle complications in levo-transposition of the great arteries: A case report and review of literature. World J Cardiol 2023; 15:542-552. [PMID: 37900900 PMCID: PMC10600789 DOI: 10.4330/wjc.v15.i10.542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/23/2023] [Accepted: 09/27/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Congenitally corrected levo-transposition of the great arteries (L-TGA) is a congenital heart disease in which the ventricles and great arteries are transposed from their typical anatomy. In L-TGA, the double discordance, atrioventricular and ventriculoarterial, create an acyanotic milieu which allows patients to survive their early decades, however, progressive systemic right ventricle (sRV) dysfunction creates complications later in life. sRV dysfunction and remodeling predisposes patients to intracardiac thrombus (ICT) formation. CASE SUMMARY A 40-year-old male with L-TGA presented with symptoms of acute decompensated heart failure. In childhood, he had surgical repair of a ventricular septal defect. In adulthood, he developed sRV dysfunction, systemic tricuspid valve (sTV) regurgitation, and left-bundle branch block for which he underwent cardiac resynchronization therapy. Transthoracic echocardiogram showed a sRV ejection fraction of 40%, severe sTV regurgitation, and a newly identified sRV ICT. ICT was confirmed by ultrasound-enhancing agents and transesophageal echocardiography. Our patient was optimized with guideline-directed medical therapy and diuresis. Anticoagulation was achieved with a vitamin K antagonist (VKA) and he was later referred for evaluation by advanced heart failure and heart transplant services. CONCLUSION Anticoagulation with VKA is the mainstay of treatment in the absence of conclusive data supporting direct oral anticoagulant use in ICT in patients with congenital heart disease. This case illustrates the natural history of L-TGA and highlights the importance of surveillance and monitoring with dedicated cardiac imaging to identify complications.
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Affiliation(s)
- Mohamed Ramzi Almajed
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, United States
| | - Abdulla Almajed
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama 00000, Bahrain
| | - Naoshin Khan
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, United States
| | - Mark S Obri
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, United States
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15
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Hasun M, Wisser W, Heger M, Sow L, Schönbrunn N, Finsterer J, Stöllberger C, Weidinger F. Surgical Transmitral Thrombectomy to Prevent Recurrent Stroke in Acute Myocardial Infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 53S:S307-S312. [PMID: 36096876 DOI: 10.1016/j.carrev.2022.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022]
Abstract
Left ventricular (LV)-thrombi occur in up to 14 % of patients with acute myocardial infarction (AMI) in the era of primary percutaneous coronary intervention. For these patients, anticoagulant therapy (AC) is recommended by AMI-guidelines. When, despite AC, LV-thrombi lead to embolism, surgical thrombectomy is an option, which is not mentioned or not recommended in AMI-guidelines. We report a 46-year old female patient with AMI. An 80 % stenosis of the proximal left anterior descending coronary artery was treated by a drug-eluting stent. Thrombi within the akinetic LV-apex became mobile despite AC and dual antiplatelet therapy, and a cerebellar stroke occurred. By a transmitral surgical approach with endoscopic assistance the thrombi were completely removed. Postoperative course and 12-months follow-up were uneventful. LV-thrombi should be observed carefully regarding changes in morphology. Surgical thrombectomy of LV-thrombi is a rare treatment option to prevent imminent embolism. Benefits versus risks of surgical removal of LV-thrombi need to be carefully weighted.
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Affiliation(s)
| | - Wilfried Wisser
- University Hospital, Department of Cardiac Sugery, Währinger Gürtel 18-20, 1090 Wien, Austria
| | - Maria Heger
- Klinik Landstraße, Juchgasse 25, 1030 Wien, Austria
| | - Lisa Sow
- Klinik Landstraße, Juchgasse 25, 1030 Wien, Austria
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16
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Abazid RM, Frost A, Manian U, Bagur R, Tzemos N. Natural History of Left Ventricle Thrombus After ST-Segment Elevation Myocardial Infarction: An Echocardiographic Contrast Study. JACC. ADVANCES 2023; 2:100329. [PMID: 38938226 PMCID: PMC11198265 DOI: 10.1016/j.jacadv.2023.100329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
| | | | | | | | - Nikolaos Tzemos
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, University Hospital, 339 Windermere Road, PO Box 5010, London, Ontario N6A 5A5, Canada
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17
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Mainali S. Neurologic Complications of Cardiac and Pulmonary Disease. Continuum (Minneap Minn) 2023; 29:684-707. [PMID: 37341327 DOI: 10.1212/con.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE The heart and lungs work as a functional unit through a complex interplay. The cardiorespiratory system is responsible for the delivery of oxygen and energy substrates to the brain. Therefore, diseases of the heart and lungs can lead to various neurologic illnesses. This article reviews various cardiac and pulmonary pathologies that can lead to neurologic injury and discusses the relevant pathophysiologic mechanisms. LATEST DEVELOPMENTS We have lived through unprecedented times over the past 3 years with the emergence and rapid spread of the COVID-19 pandemic. Given the effects of COVID-19 on the lungs and heart, an increased incidence of hypoxic-ischemic brain injury and stroke associated with cardiorespiratory pathologies has been observed. Newer evidence has questioned the benefit of induced hypothermia in patients with out-of-hospital cardiac arrest. Further, global collaborative initiatives such as the Curing Coma Campaign are underway with the goal of improving the care of patients with coma and disorders of consciousness, including those resulting from cardiac and pulmonary pathologies. ESSENTIAL POINTS The neurologic complications of cardiorespiratory disorders are common and present in various forms such as stroke or hypoxic and anoxic injury related to cardiac or respiratory failure. With the emergence of the COVID-19 pandemic, neurologic complications have increased in recent years. Given the intimate and interdependent dynamics of the heart, lungs, and brain, it is crucial for neurologists to be aware of the interplay between these organs.
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18
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Dilemmas in hematology: consults in patients with arterial thrombosis. J Thromb Haemost 2023; 21:421-432. [PMID: 36696207 DOI: 10.1016/j.jtha.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/21/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Arterial thrombotic events, particularly ischemic stroke and myocardial infarction, are common, and mostly occur due to atherosclerotic disease or arrhythmias. The diagnosis and management of the majority of such events occurs without the involvement of a hematologist, following established guidelines or pathways. In this review, we discuss 3 scenarios in which optimal management is less certain. These scenarios concern patients with a left ventricular thrombus, in whom the duration and choice of anticoagulant has been debated, patients with ischemic stroke and a patent foramen ovale, in whom the role of patent foramen ovale closure requires careful consideration, and the role of thrombophilia testing in young patients after a stroke or myocardial infarction, which remains an area of contention. We consider the available evidence and published guidelines in order to provide a practical, evidence-based approach to these 3 clinical scenarios.
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Hudec S, Hutyra M, Precek J, Latal J, Nykl R, Spacek M, Sluka M, Sanak D, Tudos Z, Pastucha D, Taborsky M. Determination of the prevalence and predictors of ventricular thrombus with assessment of the risk of systemic embolization to the CNS in patients after acute myocardial infarction using magnetic resonance imaging, echocardiography and cardiac markers - a prospective, unicentric, observational study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023. [PMID: 38214057 DOI: 10.5507/bp.2023.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Left ventricular thrombus (LVT) formation is one of the well-known and serious complications of acute myocardial infarction (AMI) due to the risk of systemic arterial embolization (SE). To diagnose LVT, echocardiography (TTE) is used. Late gadolinium-enhanced cardiovascular magnetic resonance (DE-CMR) is the gold standard for diagnosing LVT. OBJECTIVES The aim of this observational study was to determine the role of transthoracic echocardiography and cardiac markers in predicting the occurrence of LVT compared with a reference cardiac imaging (DE-CMR) and to determine the risk of systemic embolization to the CNS using brain MRA. METHODS Seventy patients after MI managed by percutaneous coronary intervention (localization: 92.9% anterior wall, 7% other; median age 58.7 years) were initially examined by transthoracic echocardiography (TTE, n=69) with a focus on LVT detection. Patients were then referred for DE-CMR (n=55). Laboratory determination of cardiac markers (Troponin T and NTproBNP) was carried out in all. Brain MRA was performed 1 year apart (n=51). RESULTS The prevalence of LVT detected by echocardiography: (n=11/69, i.e. 15.9%); by DE-CMR: (n=9/55, i.e. 16.7%). Statistically significant parameters to predict the occurrence of LVT after AMI (cut off value): (a) detected by echocardiography: anamnestic data - delay (≥ 5 hours), echocardiographic parameters - left atrial volume index (LAVI≥ 32 mL/m2), LV EF Simpson biplane and estimated (≤ 42%), tissue Doppler determination of septal A wave velocity (≤ 7.5cm/s); (b) detected by DE-CMR: anamnestic data - delay (≥ 13 hours), DE-CMR parameters - left ventricular end-diastolic diameter (≥ 54mm). The value of cardiac markers (Troponin T and NTproBNP in ng/L) in LVT detected by echocardiography did not reach statistical significance. In LVT detected by DE-CMR, NTproBNP was statistically significantly increased at 1 month after AMI onset (no optimal cut-off value could be determined). There was no statistically significant association between the LVT detection (both modalities) and the occurrence of clinically manifest and silent cardioembolic events. CONCLUSION Our study confirmed a relatively high prevalence of LVT in the high-risk group of patients with anterior wall STEMI. Due to the low prevalence of thromboembolic complications, no significant association between the LVT detection and the occurrence of a cardioembolic event was demonstrated.
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Affiliation(s)
- Stepan Hudec
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Precek
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Latal
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Radomir Nykl
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Miloslav Spacek
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Sluka
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Daniel Sanak
- Complex Cerebrovascular Centre, Department of Neurology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Zbynek Tudos
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Dalibor Pastucha
- Department of Rehabilitation and Sports Medicine, Faculty of Medicine, University of Ostrava and University Hospital Ostrava, Ostrava, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
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Time Trends of Ventricular Reconstruction and Outcomes among Patients with Left Ventricular Thrombus and Aneurysms. J Cardiovasc Dev Dis 2022; 9:jcdd9120464. [PMID: 36547461 PMCID: PMC9784406 DOI: 10.3390/jcdd9120464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Clinical guidelines recommend surgical intervention when left ventricular thrombus (LVT) is complicated with left ventricular aneurysm (LVA). Objectives: This study aimed to review the changes in the treatment of LVT combined with LVA over the past 12 years at our center and to compare the efficacy of medical therapy and surgical treatment on patient outcomes. Methods: Between January 2009 and June 2021, 723 patients with LVT combined with LVA were enrolled, of whom 205 received surgical ventricular reconstruction (SVR) therapy and 518 received medical therapy. The following clinical outcomes were gathered via observation: all-cause death, cardiovascular death, and major adverse cardiovascular and cerebrovascular events (MACCEs; defined as the composite of cardiovascular death, ischemic stroke, and acute myocardial infarction). The median follow-up time was 1403 [707, 2402] days. Results: The proportion of SVR dropped yearly in this group of patients, from a peak of 64.5% in 2010 to 7.5% in 2021 (p for trend < 0.001). Meanwhile, the proportion of anticoagulant use increased quickly, from 8.0% in 2016 to 67.9% in 2021 (p for trend < 0.001). The incidence rates of all-cause mortality, cardiovascular death, and MACCEs were 12.9% (n = 93), 10.5% (n = 76), and 14.7% (n = 106), respectively. In the multivariable analysis, there were no significant differences in all-cause death (HR of 0.60, 95% CI of 0.32−1.13, p = 0.11), cardiovascular death (HR of 0.79, 95% CI of 0.41−1.50, p = 0.5), and MACCEs (HR of 0.82, 95% CI of 0.49−1.38, p = 0.5) between the two groups. The competing risk regression performed in the propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analyses was in line with the unmatched analysis. Conclusions: The rate of SVR dropped significantly among patients with both LVT and LVA, while there was an improvement in oral anticoagulant utilization. SVR with thrombus removal did not improve all-cause mortality and cardiovascular outcomes in patients with LVT and LVA. Ventricular aneurysm with thrombus may not be an indication for surgery.
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21
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Youssef AA, Alrefae MA, Khalil HH, Abdullah HI, Khalifa ZS, Al Shaban AA, Wali HA, AlRajab MR, Saleh OM, Nashy BN. Apixaban in Patients with Post-Myocardial Infarction Left Ventricular Thrombus: A Randomized Clinical Trial. CJC Open 2022; 5:191-199. [PMID: 37013071 PMCID: PMC10066447 DOI: 10.1016/j.cjco.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
Background Direct oral anticoagulants are frequently used to treat post-myocardial infarction (MI) left ventricular thrombus (LVT). This study was conducted to evaluate the efficacy and safety of use of apixaban, compared to the standard warfarin therapy, in post-MI LVT. Methods This open-label, randomized controlled trial included patients with post-acute or recent anterior wall MI with transthoracic echocardiography-confirmed LVT. Patients were randomized to receive either apixaban 5 mg twice daily or warfarin to achieve an international normalized ratio of 2-3, in addition to dual antiplatelet therapy. The primary endpoint was LVT resolution at 3 months, with a noninferiority margin of 95% for apixaban compared to warfarin. The secondary endpoint was major adverse cardiovascular events (MACE) or any relevant bleeding according to the Bleeding Academic Research Consortium (BARC) classification. Results Fifty patients were enrolled from 3 centres. The use of dual or single antiplatelet agents was similar in the 2 groups. The number of 1-, 3-, and 6-month LVT resolutions were 10 (40.0%), 19 (76.0%), and 23 (92.0%) in the apixaban group, and 14 (56%), 20 (80.0%), and 24 (96.0%) in the warfarin group, respectively, without significant differences (P < 0.036 for noninferiority at 3 months). Patients taking warfarin required longer hospital stays and more outpatient visits. Multivariate adjustment analysis revealed left ventricular aneurysm, larger baseline LVT area and lower left ventricular ejection fraction to be independent predictors of LVT persistence at 3 months. No MACE occurred in either group; 1 BARC-2 bleeding event occurred with warfarin. Conclusions Apixaban was not inferior to warfarin in the resolution of post-MI LVT.
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Affiliation(s)
- Ali A. Youssef
- Saud Albabtain Cardiac Centre, Dammam, Saudi Arabia
- Department of Cardiology, Suez Canal University, Ismailia, Egypt
- Corresponding author: Dr Ali A. Youssef, Department of Cardiology, Suez Canal University, 4.5 Km the Ring Road, Ismailia, Egypt. Tel.: +201097797054; fax: +20643205208
| | | | - Hesham H. Khalil
- Saud Albabtain Cardiac Centre, Dammam, Saudi Arabia
- National Heart Institute, Cairo, Egypt
| | | | - Zizi S. Khalifa
- Department of Cardiology, Zagazig University, Zagazig, Egypt
| | | | | | | | - Omar M. Saleh
- Department of Cardiology, Suez Canal University, Ismailia, Egypt
| | - Baher N. Nashy
- Department of Cardiology, Zagazig University, Zagazig, Egypt
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22
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DI Muro FM, Russo G, DI Mario C, Pedicino D. Direct oral anticoagulants versus vitamin K antagonists in the treatment of left ventricular thrombosis: when off label becomes routine. Minerva Cardiol Angiol 2022; 70:663-665. [PMID: 36700666 DOI: 10.23736/s2724-5683.22.06047-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Francesca M DI Muro
- Unit of Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Giulio Russo
- Department of Biomedicine and Prevention, Policlinico Tor Vergata, Tor Vergata University, Rome, Italy
| | - Carlo DI Mario
- Unit of Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Daniela Pedicino
- Department of Cardiovascular Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy - .,Department of Cardiovascular and Pulmonary Sciences, Sacred Heart Catholic University, Rome, Italy
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23
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Condello F, Maurina M, Chiarito M, Sturla M, Terzi R, Fazzari F, Sanz-Sanchez J, Cannata F, Condorelli G, Stefanini GG. Direct oral anticoagulants versus vitamin K antagonists in the treatment of left ventricular thrombosis: a systematic review and meta-analysis. Minerva Cardiol Angiol 2022; 70:666-676. [PMID: 35080357 DOI: 10.23736/s2724-5683.21.05893-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Evidence about the use of direct oral anticoagulants (DOACs) in patients with left ventricular thrombosis (LVT) are emerging. The aim of our study was to provide a comprehensive synthesis of the available evidence concerning the clinical effects of DOACs versus vitamin K antagonists (VKAs) in LVT treatment. EVIDENCE ACQUISITION Systematic search of studies evaluating DOACs versus VKAs use in patients with LVT was performed on May 11th, 2021. Data were pooled by meta-analysis using a random-effects model. Odds ratios (OR) with relative 95% confidence intervals (CI) were used as measures of effect estimates. The primary efficacy and safety endpoint were ischemic stroke and any bleeding, respectively. Secondary endpoints were LVT resolution, systemic embolism, major bleeding, hemorrhagic stroke, and all cause death. EVIDENCE SYNTHESIS Twenty studies were included in the meta-analysis: 1,391 patients were treated with DOACs and 1,534 with VKAs. A significant reduction in the risk of ischemic stroke (OR 0.67, 95% CI, 0.45-0.98, P=0.048, number needed to treat to benefit [NNTB] 22 [95% CI 15-43]) and any bleeding (OR 0.64, 95% CI 0.46-0.89, P=0.009, NNTB 26 [95% CI 16-80]) was observed with DOACs compared to VKAs. No statistically significant difference was observed among the two treatment arms for the secondary endpoints. CONCLUSIONS Compared to VKAs, DOACs are associated with a reduced risk of ischemic stroke and bleeding. In light of these findings, and the practical advantages of DOACs, additional large scale randomized controlled trials are needed to confirm the benefits of DOACs in patients with LVT.
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Affiliation(s)
- Francesco Condello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Matteo Maurina
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Matteo Sturla
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Riccardo Terzi
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Fabio Fazzari
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Jorge Sanz-Sanchez
- La Fe Polytechnic University Hospital, Valencia, Spain.,Centro de Investigacion Biomedica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Francesco Cannata
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy - .,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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24
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Taoutel R, Sukhon F, Liskov S, Kreidieh B, Chandhok S. Incessant atrioventricular nodal reentrant tachycardia resulting in tachycardia-induced cardiomyopathy and catastrophic embolization of left ventricular thrombus. HeartRhythm Case Rep 2022; 9:144-147. [PMID: 36970383 PMCID: PMC10030302 DOI: 10.1016/j.hrcr.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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25
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Moreira HT, Volpe GJ, Mesquita GM, Braggion-Santos MF, Pazin-Filho A, Marin-Neto JA, Schmidt A. Association of left ventricular abnormalities with incident cerebrovascular events and sources of thromboembolism in patients with chronic Chagas cardiomyopathy. J Cardiovasc Magn Reson 2022; 24:52. [PMID: 36329520 PMCID: PMC9632087 DOI: 10.1186/s12968-022-00885-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/16/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Although Chagas cardiomyopathy is related to thromboembolic stroke, data on risk factors for cerebrovascular events in Chagas disease is limited. Thus, we assessed the relationship between left ventricular (LV) impairment and cerebrovascular events and sources of thromboembolism in patients with Chagas cardiomyopathy. METHODS This retrospective cohort included patients with chronic Chagas cardiomyopathy who underwent cardiovascular magnetic resonance (CMR). CMR was performed with a 1.5 T scanner to provide LV volumes, mass, ejection fraction (LVEF), and myocardial fibrosis. The primary outcome was a composite of incident ischemic cerebrovascular events (stroke or transient ischemic attack-TIA) and potential thromboembolic sources (atrial fibrillation (AF), atrial flutter, or intracavitary thrombus) during the follow-up. RESULTS A total of 113 patients were included. Median age was 56 years (IQR: 45-67), and 58 (51%) were women. The median LVEF was 53% (IQR: 41-62). LV aneurysms and LV fibrosis were present in 38 (34%) and 76 (67%) individuals, respectively. The median follow-up time was 6.9 years, with 29 events: 11 cerebrovascular events, 16 had AF or atrial flutter, and two had LV apical thrombosis. In the multivariable model, only lower LVEF remained significantly associated with the outcomes (HR: 0.96, 95% CI: 0.93-0.99). Patients with reduced LVEF lower than 40% had a much higher risk of cerebrovascular events and thromboembolic sources (HR: 3.16 95% CI: 1.38-7.25) than those with normal LVEF. The combined incidence rate of the combined events in chronic Chagas cardiomyopathy patients with reduced LVEF was 13.9 new cases per 100 persons-year. CONCLUSIONS LV systolic dysfunction is an independent predictor of adverse cerebrovascular events and potential sources of thromboembolism in patients with chronic Chagas cardiomyopathy.
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Affiliation(s)
- Henrique Turin Moreira
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - Gustavo Jardim Volpe
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - Gustavo Marques Mesquita
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - Maria Fernanda Braggion-Santos
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - Antonio Pazin-Filho
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - José Antonio Marin-Neto
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - André Schmidt
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
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26
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Levine GN, McEvoy JW, Fang JC, Ibeh C, McCarthy CP, Misra A, Shah ZI, Shenoy C, Spinler SA, Vallurupalli S, Lip GYH. Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e205-e223. [PMID: 36106537 DOI: 10.1161/cir.0000000000001092] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Despite the many advances in cardiovascular medicine, decisions concerning the diagnosis, prevention, and treatment of left ventricular (LV) thrombus often remain challenging. There are only limited organizational guideline recommendations with regard to LV thrombus. Furthermore, management issues in current practice are increasingly complex, including concerns about adding oral anticoagulant therapy to dual antiplatelet therapy, the availability of direct oral anticoagulants as a potential alternative option to traditional vitamin K antagonists, and the use of diagnostic modalities such as cardiac magnetic resonance imaging, which has greater sensitivity for LV thrombus detection than echocardiography. Therefore, this American Heart Association scientific statement was commissioned with the goals of addressing 8 key clinical management questions related to LV thrombus, including the prevention and treatment after myocardial infarction, prevention and treatment in dilated cardiomyopathy, management of mural (laminated) thrombus, imaging of LV thrombus, direct oral anticoagulants as an alternative to warfarin, treatments other than oral anticoagulants for LV thrombus (eg, dual antiplatelet therapy, fibrinolysis, surgical excision), and the approach to persistent LV thrombus despite anticoagulation therapy. Practical management suggestions in the form of text, tables, and flow diagrams based on careful and critical review of actual study data as formulated by this multidisciplinary writing committee are given.
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27
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Zhang Q, Zhang Z, Zheng H, Qu M, Li S, Yang P, Si D, Zhang W. Rivaroxaban in heart failure patients with left ventricular thrombus: A retrospective study. Front Pharmacol 2022; 13:1008031. [PMID: 36278225 PMCID: PMC9585209 DOI: 10.3389/fphar.2022.1008031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/26/2022] [Indexed: 12/02/2022] Open
Abstract
Background: The role of rivaroxaban in patients with heart failure (HF) combined with left ventricular (LV) thrombus remains unknown in current guideline-directed anticoagulant therapy. The aim of this study was to investigate the impact on clinical outcomes of rivaroxaban compared to vitamin K antagonists (VKAs) in patients with HF combined with LV thrombus. Methods: We retrospectively extracted clinical, echocardiographic and follow-up data of HF patients (all classifications) admitted at China-Japan Union Hospital of Jilin University from January 2017 to June 2021. A total of 198 patients with HF were identified with LV thrombus by echocardiography, 78 of them were managed with VKAs, 109 with rivaroxaban. Results: The median follow-up was 17.0 months (interquartile range: 6.0–24.0 months). High rates of major cardiovascular adverse events (MACEs) were observed in both the rivaroxaban and VKAs groups (49.5% vs. 57.7%). However, rivaroxaban versus VKAs observed a decrease in MACEs (adjusted HR:0.636; 95%CI:0.418–0.970; p = 0.035) and systemic embolism (4.6% vs. 12.8%; adjusted HR:0.318; 95%CI:0.108–0.933; p = 0.037; Gray’s test p = 0.041) but was not found to have a benefit with regard to LV thrombus resolution (59.6% vs. 70.6%; adjusted HR: 1.303; 95% CI:0.898–1.890; p = 0.163; Gray’s test p = 0.073). Additionally, there was no significant between-group difference in the rate of International Society on Thrombosis and Hemostasis (ISTH) bleeding events. Conclusion: Our data found that in populations with HF combined with LV thrombus, the overall prognosis in both the rivaroxaban and VKAs groups was catastrophic. Although rivaroxaban improved the prognosis to some extent, a considerable need remains for new treatments to improve their clinical course.
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Affiliation(s)
- Qian Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Zhongfan Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Haikuo Zheng
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ming Qu
- Department of Gastroenterology, Endoscopy Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Shouping Li
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ping Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Daoyuan Si
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Daoyuan Si, ; Wenqi Zhang,
| | - Wenqi Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Daoyuan Si, ; Wenqi Zhang,
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28
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Van Le T, Truong T, Phung H, Ngo A, Truong VT, Nguyen DH. Bilateral Renal Artery Thromboembolism During Thrombolytic Therapy for Embolism-Induced Acute Limb Ischemia. JACC Case Rep 2022; 4:1256-1262. [PMID: 36406914 PMCID: PMC9666748 DOI: 10.1016/j.jaccas.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 06/16/2023]
Abstract
We report a case of bilateral renal infarction following thrombolytic and anticoagulant therapy for left ventricular embolism-induced lower leg artery ischemia. Imaging demonstrated thrombi from the left ventricle leading to bilateral renal arterial occlusion. Catheter embolectomy and long-term oral anticoagulant therapy were initiated, and the patient recovered with no residual complications. (Level of Difficulty: Intermediate.).
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Affiliation(s)
| | - Thai Truong
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Hung Phung
- Quang Tri General Hospital, Dong Ha, Viet Nam
| | - An Ngo
- University of Pittsburgh Medical Center-McKeesport, McKeesport, Pennsylvania, USA
| | - Vien Thanh Truong
- Department of Internal Medicine, Nazareth Hospital, Philadelphia, Pennsylvania, USA
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29
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Serenelli M, Pavasini R, Vitali F, Tonet E, Cantone A, Di Ienno L, Pompei G, Bertini M, Campo G. Direct oral anticoagulants for the treatment of left ventricular thrombosis: an updated systematic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2022; 23:672-677. [PMID: 36099074 DOI: 10.2459/jcm.0000000000001368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS This meta-analysis aims to compare direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in the setting of left ventricular thrombosis (LVT). METHOD AND RESULTS We systematically searched MEDLINE, Cochrane Library, Biomed Central and Web of Science for trials comparing DOACs versus VKAs in the setting of LVT and reporting outcome data on thrombosis resolution, stroke and bleeding. Fourteen studies were finally selected. The Mantel-Haenszel method with a random effect model was used for the pooled analysis. The primary outcome was the occurrence of LVT resolution. The secondary outcomes were the occurrence of stroke or bleeding during treatment. One thousand three hundred and thirty-two patients were included in the analysis for the primary outcome. Of these, 424 were treated with DOACs and 908 with VKAs. The pooled odds ratio (OR) for the primary outcome was 1.00 [95% confidence interval (95% CI) 0.77-1.31, I2 0.0%], reflecting equal effect in terms of thrombus resolution. Overall, 2290 patients, 608 on DOACs and 1682 on VKAs were included in the analysis of stroke occurrence, showing reduced risk of events in patients treated with DOACs (pooled OR 0.58, 95% CI 0.36-0.93; I2 0.0%) as well as for bleeding occurrence (number of patients included 2139; pooled OR 0.64, 95% CI 0.44-0.94; I2 0.0%). CONCLUSION Compared with VKAs, we found DOACs to have similar efficacy on thrombus resolution and favorable effects on stroke reduction and bleedings. DOACs should be considered as an alternative treatment for LVT. Large prospective randomized clinical trials are needed to confirm this exploratory finding.
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Affiliation(s)
- Matteo Serenelli
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona (FE), Italy
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30
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Agewall S. Treating patients with anticoagulants and antiplatelet drugs is always a balance between risk for thrombosis vs. risk for bleeding. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:645-647. [PMID: 36172980 DOI: 10.1093/ehjcvp/pvac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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31
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Chen Y, Zhu M, Wang K, Xu Q, Ma J. Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Treatment of Left Ventricular Thrombus: An Updated Meta-Analysis of Cohort Studies and Randomized Controlled Trials. J Cardiovasc Pharmacol 2022; 79:935-940. [PMID: 35383658 PMCID: PMC9162267 DOI: 10.1097/fjc.0000000000001270] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/11/2022] [Indexed: 12/02/2022]
Abstract
ABSTRACT Left ventricular thrombi (LVTs) increase the risk of stroke, systemic embolism, and subsequent death. Current guidelines recommend vitamin K antagonists (VKAs) as first-line treatment for LVT. Direct oral anticoagulants (DOACs) are increasingly used as alternatives to warfarin for the treatment of LVT. However, the efficacy and safety of DOACs versus VKAs remain controversial. Thus, we conducted an updated meta-analysis of DOACs versus VKAs for LVT treatment. We systematically searched PubMed, Embase, ClinicalTrials, and Cochrane Library databases for relevant articles published before December 11, 2021. The relative risks (RRs) with 95% confidence intervals (CIs) were calculated for each study. The meta-analysis included 12 cohort studies and 3 randomized controlled trials with a total of 2334 patients. We found that DOACs had a lower risk of clinically significant bleeding than VKAs (RR = 0.6; 95% CI, 0.39 to 0.90; P = 0.01; I2 = 0%). There was no difference in LVT resolution (RR = 1.01; 95% CI, 0.93 to 1.09; P = 0.48; I2 = 0%), stroke and/or systematic embolic events (RR = 0.87; 95% CI, 0.11 to 1.55; P = 0.2; I2 = 30%), and all-cause mortality (RR = 0.9; 95% CI, 0.58 to 1.4; P = 0.65; I2 = 0%). Overall, DOACs are noninferior to warfarin in LVT treatment but have a lower risk of clinically significant bleeding. This suggests that DOACs might be better alternatives to warfarin for LVT treatment.
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Affiliation(s)
- Yanming Chen
- Department of Cardiology, the First Medical Center, Chinese PLA General Hospital, Beijing, China; and
| | - Mei Zhu
- Department of Cardiology, the First Medical Center, Chinese PLA General Hospital, Beijing, China; and
| | - Kai Wang
- Department of cardiovascular medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Qiang Xu
- Department of Cardiology, the First Medical Center, Chinese PLA General Hospital, Beijing, China; and
| | - Jing Ma
- Department of Cardiology, the First Medical Center, Chinese PLA General Hospital, Beijing, China; and
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32
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Merlo AC, Benenati S, Masoero G, Zingarelli A, Ameri P, Porto I. Direct oral anticoagulants versus vitamin-K antagonists in patients with left ventricular thrombus: A systematic review and meta-analysis. Vascul Pharmacol 2022; 144:106996. [DOI: 10.1016/j.vph.2022.106996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/24/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022]
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33
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Camaj A, Fuster V, Giustino G, Bienstock SW, Sternheim D, Mehran R, Dangas GD, Kini A, Sharma SK, Halperin J, Dweck MR, Goldman ME. Left Ventricular Thrombus Following Acute Myocardial Infarction: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:1010-1022. [PMID: 35272796 DOI: 10.1016/j.jacc.2022.01.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 12/11/2022]
Abstract
The incidence of left ventricular (LV) thrombus following acute myocardial infarction has markedly declined in recent decades caused by advancements in reperfusion and antithrombotic therapies. Despite this, embolic events remain the most feared complication of LV thrombus necessitating systemic anticoagulation. Mechanistically, LV thrombus development depends on Virchow's triad (ie, endothelial injury from myocardial infarction, blood stasis from LV dysfunction, and hypercoagulability triggered by inflammation, with each of these elements representing potential therapeutic targets). Diagnostic modalities include transthoracic echocardiography with or without ultrasound-enhancing agents and cardiac magnetic resonance. Most LV thrombi develop within the first 2 weeks post-acute myocardial infarction, and the role of surveillance imaging appears limited. Vitamin K antagonists remain the mainstay of therapy because the efficacy of direct oral anticoagulants is less well established. Only meager data support the routine use of prophylactic anticoagulation, even in high-risk patients.
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Affiliation(s)
- Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/acamajmd
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/g_giustinomd
| | - Solomon W Bienstock
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/swbienmd
| | - David Sternheim
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/drroxmehran
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/georgedangas
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/doctorkini
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Halperin
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Martin E Goldman
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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34
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May JE. Unexplained arterial thrombosis: approach to diagnosis and treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:76-84. [PMID: 34889390 PMCID: PMC8791102 DOI: 10.1182/hematology.2021000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Arterial thrombotic events in younger patients without a readily apparent etiology present significant diagnostic and management challenges. We present a structured approach to diagnosis with consideration of common causes, including atherosclerosis and embolism, as well as uncommon causes, including medications and substances, vascular and anatomic abnormalities, systemic disorders, and thrombophilias. We highlight areas of management that have evolved within the past 5 years, including the use of dual-pathway inhibition in atherosclerotic disease, antithrombotic therapy selection in embolic stroke of undetermined source and left ventricular thrombus, the role of closure of patent foramen ovale for secondary stroke prevention, and the thrombotic potential of coronavirus disease 2019 infection and vaccination. We conclude with a representative case to illustrate the application of the diagnostic framework and discuss the importance of consideration of bleeding risk and patient preference in determining the appropriate management plan.
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Affiliation(s)
- Jori E. May
- Department of Medicine, Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
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35
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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] [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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36
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Ascione G, Denti P. Transcatheter Mitral Valve Replacement and Thrombosis: A Review. Front Cardiovasc Med 2021; 8:621258. [PMID: 34150861 PMCID: PMC8212998 DOI: 10.3389/fcvm.2021.621258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 04/12/2021] [Indexed: 11/25/2022] Open
Abstract
Mitral regurgitation is the most prevalent form of moderate or severe valve disease in developed countries. Surgery represents the standard of care for symptomatic patients with severe mitral regurgitation, but up to 50% of patients are denied surgery because of high surgical risk. In this context, different transcatheter options have been developed to address this unmet need. Transcatheter mitral valve replacement (TMVR) is an emergent field representing an alternative option in high complex contexts when transcatheter mitral valve repair is not feasible or suboptimal due to anatomical issues. However, TMVR is burdened by some device-specific issues (device malposition, migration or embolization, left ventricular outflow tract obstruction, hemolysis, thrombosis, stroke). Here we discuss the thrombotic risk of TMVR and current evidence about anticoagulation therapy after TMVR.
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Affiliation(s)
- Guido Ascione
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo Denti
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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37
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Di Odoardo LAF, Stefanini GG, Vicenzi M. Uncertainties about left ventricular thrombus after STEMI. Nat Rev Cardiol 2021; 18:381-382. [PMID: 33707769 DOI: 10.1038/s41569-021-00539-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 01/30/2023]
Affiliation(s)
- Luca A F Di Odoardo
- Cardiology Unit, Cardiotoracovascular Department, Legnano Hospital, ASST Ovest Milanese, Milan, Italy.
| | - Giulio G Stefanini
- Humanitas Clinical and Research Center IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Marco Vicenzi
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Cardiovascular Disease Unit, Department of Internal Medicine, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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38
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Barkhudaryan A, Doehner W, Scherbakov N. Ischemic Stroke and Heart Failure: Facts and Numbers. An Update. J Clin Med 2021; 10:jcm10051146. [PMID: 33803423 PMCID: PMC7967189 DOI: 10.3390/jcm10051146] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/26/2021] [Accepted: 02/27/2021] [Indexed: 12/22/2022] Open
Abstract
Heart failure (HF) is a severe clinical syndrome accompanied by a number of comorbidities. Ischemic stroke occurs frequently in patients with HF as a complication of the disease. In the present review, we aimed to summarize the current state of research on the role of cardio–cerebral interactions in the prevalence, etiology, and prognosis of both diseases. The main pathophysiological mechanisms underlying the development of stroke in HF and vice versa are discussed. In addition, we reviewed the results of recent clinical trials investigating the prevalence and prevention of stroke in patients with HF.
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Affiliation(s)
- Anush Barkhudaryan
- Department of Cardiology, Clinic of General and Invasive Cardiology, University Hospital No 1, Yerevan State Medical University, Yerevan 0025, Armenia;
- Cardiovascular Research Institute Basel, University Hospital Basel, 4056 Basel, Switzerland
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
- Department of Cardiology, Campus Virchow, Charité-Universitätsmedizin Berlin, DZHK (German Center for Cardiovascular Research), Partner Site Berlin, 13353 Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Nadja Scherbakov
- BIH Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
- Department of Cardiology, Campus Virchow, Charité-Universitätsmedizin Berlin, DZHK (German Center for Cardiovascular Research), Partner Site Berlin, 13353 Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Correspondence:
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39
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Cruz Rodriguez JB, Okajima K, Greenberg BH. Management of left ventricular thrombus: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:520. [PMID: 33850917 PMCID: PMC8039643 DOI: 10.21037/atm-20-7839] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.
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Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Diseases, Texas Tech University Health Science Center, El Paso, TX, USA
| | - Kazue Okajima
- Division of Cardiovascular Diseases, Texas Tech University Health Science Center, El Paso, TX, USA
| | - Barry H Greenberg
- Heart Failure/Cardiac Transplantation Program, University of California, San Diego, CA, USA
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40
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Zhou K, Zhang X, Xiao Y, Li D, Song G. Effectiveness and safety of direct-acting oral anticoagulants compared to vitamin K antagonists in patients with left ventricular thrombus: A meta-analysis. Thromb Res 2020; 197:185-191. [PMID: 33227655 DOI: 10.1016/j.thromres.2020.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/27/2020] [Accepted: 11/13/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Left ventricular thrombus (LVT) is a complication of multiple cardiovascular diseases. There has been an increasing trend of off-label using direct-acting oral anticoagulants (DOACs) for the treatment of patients with LVT. The effectiveness and safety of DOACs remain to be determined. METHOD We searched for publications (PubMed, MEDLINE, Web of Science, EMBASE, Scopus, and ClinicalTrials.gov) comparing DOACs with Vitamin K antagonists (VKAs) in patients with LVT. We estimated odds ratio (OR) and 95% confidence intervals (CIs) for stroke, systemic embolism, major bleeding events, and thrombus resolution as the effectiveness and safety outcomes. The subgroup analysis and meta-regression were also performed. RESULTS Nine retrospective observational studies with a total of 2028 participants were included. DOACs demonstrated a similar risk of stroke, systemic embolism, major bleeding events, and thrombus resolution (OR = 0.79, 95% CI: 0.50-1.23; OR = 1.22, 95% CI: 0.65-2.26; OR = 0.82, 95% CI: 0.47-1.42; OR = 1.34, 95% CI: 0.62-2.90, respectively). CONCLUSIONS There is no difference between DOACs and VKAs in patients with LVT from the perspectives of stroke, systemic embolism, major bleeding events, and thrombus resolution. Prospective randomized controlled trials with adequate sample sizes are urgently needed to confirm findings.
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Affiliation(s)
- Ke Zhou
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Xintong Zhang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yangjie Xiao
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dongyu Li
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China.
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41
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Ballestri S, Capitelli M, Fontana MC, Arioli D, Romagnoli E, Graziosi C, Lonardo A, Marietta M, Dentali F, Cioni G. Direct Oral Anticoagulants in Patients with Liver Disease in the Era of Non-Alcoholic Fatty Liver Disease Global Epidemic: A Narrative Review. Adv Ther 2020; 37:1910-1932. [PMID: 32285340 PMCID: PMC7467481 DOI: 10.1007/s12325-020-01307-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent and relevant healthcare issues. Direct oral anticoagulants (DOACs) are now the first-choice for anticoagulant treatment of these conditions displaying a better efficacy/safety profile than vitamin-K antagonists, mainly due to significantly reduced risk of major bleeding, especially of intracranial haemorrhage. Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in developed countries showing a continuously growing prevalence. Nonalcoholic steatohepatitis (NASH), its evolutive form, will be the leading cause for liver transplantation by 2020. NAFLD is independently associated with an increased risk of abnormalities of cardiac structure and function, including cardiac rhythm disorders (mainly AF). Moreover, data suggest an increased risk of unprovoked VTE associated with NAFLD/NASH. Therefore, a growing number of patients with chronic liver disease (CLD) will be candidate for anticoagulant therapy in the near future. Cirrhosis of any etiology is characterized by an unstable thrombosis/bleeding haemostatic balance, making anticoagulant therapy particularly challenging in this condition. Given that patients with significant active liver disease and cirrhosis were excluded from all pivotal randomized controlled trials on DOACs, this comprehensive review aims at critically discussing real-world evidence, including the latest population studies, regarding the use of DOACs in patients with CLD/cirrhosis.
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Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy.
| | - Mariano Capitelli
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
| | | | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Catia Graziosi
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
| | - Amedeo Lonardo
- Metabolic Syndrome Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Giorgio Cioni
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
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