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Mehrpooya M, Barakzehi MR, Nikoobakhsh M. Evaluation of the safety and efficacy of direct oral anticoagulants compared with vitamin-k antagonists in the treatment of left ventricular thrombosis. A systematic review and meta-analysis. Heart Lung 2024; 67:121-136. [PMID: 38754272 DOI: 10.1016/j.hrtlng.2024.04.019] [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: 12/19/2023] [Revised: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Since the introduction of direct oral anticoagulants (DOACs) and their comparison with vitamin K antagonists (VKAs), conflicting results have been reported regarding the optimal treatment for left ventricular thrombosis (LVT). OBJECTIVES In this meta-analysis, we intend to comprehensively evaluate the safety and efficacy of these treatments. METHODS All clinical trials and cohorts that compared the efficacy or safety of VKAs with DOACs in the treatment of LVTs were systematically searched until April 15, 2023. RESULTS The results of 32 studies with a pooled sample size of 4213 patients were extracted for meta-analysis. DOACs, especially rivaroxaban and apixaban, cause faster resolution, lower mortality, and fewer complications (SSE and bleeding events) than VKAs in the management of LVTs. CONCLUSION Compared with VKAs, DOACs result in significantly faster (only rivaroxaban) and safer resolution of left ventricular thrombosis.
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Affiliation(s)
- Maryam Mehrpooya
- Department of Cardiology, Imam Khomeini Hospital Complex of Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Rafi Barakzehi
- Department of Cardiology, Tehran Heart center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Nikoobakhsh
- Department of internal medicine, Yazd Islamic Azad University, Yazd, Iran.
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2
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Ioannou M, Leonidou E, Chaziri I, Mouzarou A. Direct Oral Anticoagulants: Navigating Through Clinical Challenges. Cardiovasc Drugs Ther 2024; 38:637-650. [PMID: 37552381 DOI: 10.1007/s10557-023-07499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several cardiovascular conditions. Since then, an increasing amount of data has been added to the medical literature day by day, resulting in a dichotomy in selection of the appropriate agent, dosage, and duration of treatment for special populations with multiple comorbidities. Considering these issues, we have prepared a comprehensive review for the clinical practitioner, to optimize the DOAC utilization in clinical practice. METHODS A thorough literature search and review was conducted, concerning mainly the last decade. Our review focused on the current guidelines and the most recently published studies in PubMed, Science Direct Scopus, and Google Scholar to date. CONCLUSION The purpose of this study is to provide guidance for healthcare professionals for making proper decisions when confronted with clinical challenges. Nevertheless, further research is required to establish DOAC superiority in complicated cases, where there is clinical uncertainty.
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Affiliation(s)
- Maria Ioannou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus.
| | - Elena Leonidou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus
| | - Ioanna Chaziri
- Department of Pneumonology, Northern Älvborg County Hospital, Trollhättan, Sweden
| | - Angeliki Mouzarou
- Department of Cardiology, General Hospital Paphos, State Health Organization Services, Paphos, Cyprus
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3
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Boivin Z, Spooner Z, Jiang C, Acus K, Lu C, She T. Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit. J Emerg Med 2024; 66:e614-e618. [PMID: 38702244 DOI: 10.1016/j.jemermed.2023.11.014] [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: 07/09/2023] [Revised: 11/08/2023] [Accepted: 11/23/2023] [Indexed: 05/06/2024]
Abstract
BACKGROUND Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality. CASE REPORT An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital. Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.
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Affiliation(s)
| | - Zhayna Spooner
- Internal Medicine Residency, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Christina Jiang
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Kirstin Acus
- Department of Emergency Medicine, Hartford Hospital, Hartford Connecticut
| | - Christina Lu
- Department of Emergency Medicine, Hartford Hospital, Hartford Connecticut
| | - Trent She
- Department of Emergency Medicine, Hartford Hospital, Hartford Connecticut
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4
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Fujino M, Noguchi T, Torii-Yoshimura T, Okuno Y, Morita Y, Nishimura K, Otsuka F, Kataoka Y, Asaumi Y, Yamagami H, Yasuda S. Outcomes of patients with cerebral microbleeds undergoing percutaneous coronary intervention and dual antiplatelet therapy. Heart Vessels 2024:10.1007/s00380-024-02404-7. [PMID: 38607378 DOI: 10.1007/s00380-024-02404-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Cerebral microbleeds (CMBs) on brain magnetic resonance imaging (MRI) are predictive of intracerebral hemorrhage (ICH). However, the risk of ICH in patients with CMBs who undergo percutaneous coronary intervention (PCI) while receiving dual antiplatelet therapy (DAPT) is unclear. MATERIALS AND METHODS We conducted a study on 329 consecutive patients with coronary artery disease who underwent PCI and were evaluated using a 3T MRI scanner. Based on T2*-weighted imaging, patients were classified into three groups: no CMBs, < 5 CMBs, or ≥ 5 CMBs. We determined the occurrence of ICH during follow-up. RESULTS At least 1 CMB was found in 109 (33%) patients. The mean number of CMBs per patient was 2.9 ± 3.6. Among the 109 patients with CMBs, 16 (15%) had ≥ 5 CMBs. Coronary stent implantation was performed in 321 patients (98%). DAPT was prescribed for 325 patients (99%). During a mean follow-up period of 2.3 years (interquartile range, 1.9-2.5 years), ICH occurred in one patient (1.1%) with four CMBs. There were no significant differences in the incidence of ICH (0% vs. 1.1% vs. 0%; p = 0.28). However, the rate of DAPT at 6 months of follow-up was significantly lower in patients with ≥ 5 CMBs than in patients with no CMBs or < 5 CMBs (89% vs. 91% vs. 66%, p = 0.026). Furthermore, there were no significant differences in systemic blood pressure during follow-up (123 ± 16 vs. 125 ± 16 vs. 118 ± 11 mmHg; p = 0.40). CONCLUSION Although a substantial number of patients who underwent PCI had cerebral microbleeds, at approximately two years of follow-up, intracerebral hemorrhage was very rare in our study population.
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Affiliation(s)
- Masashi Fujino
- Department of Cardiovascular Medicine, Suita, Osaka, Japan.
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, Suita, Osaka, Japan
| | | | - Yoshinori Okuno
- Department of Primary Care and Emergency Medicine/Healthcare Epidemiology, Kyoto university, Kyoto, Japan
| | - Yoshiaki Morita
- Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kunihiro Nishimura
- Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | - Yu Kataoka
- Department of Cardiovascular Medicine, Suita, Osaka, Japan
| | | | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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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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Clottes P, Bochaton T, Mechtouff L, Derex L, Cho TH, Fontaine J, Rascle L, Berthezène Y, Amaz C, Thibault H, Bergerot C, Nighoghossian N, Ong E. Safety and efficacy of reperfusion therapies in acute ischemic stroke related to left ventricular thrombus: A retrospective cohort study. Rev Neurol (Paris) 2024:S0035-3787(24)00417-X. [PMID: 38431497 DOI: 10.1016/j.neurol.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 12/04/2023] [Accepted: 12/17/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Left ventricular thrombus (LVT) is a source of cardiogenic embolic stroke. Conflicting data exist in the literature regarding the utilization of intravenous thrombolysis (IVT) at the acute phase of stroke in presence of LVT. We sought to assess the efficacy and safety of reperfusion therapies (IVT and/or thrombectomy) in patients with LVT. METHODS We retrospectively analyzed patients with acute ischemic stroke and proven LVT and divided them in two groups: an intervention group with patients treated by reperfusion therapies and a control group with untreated patients. RESULTS Between 2009 and 2021, 3890 patients were treated by reperfusion therapies in the Lyon stroke center, 33 of whom (0.9%) had LVT. We identified 27 control patients. There were more embolic recurrences at six months in the intervention group than in the control group (nine recurrences versus three, P=0.03, OR=13.56, 95% CI [1.5;195]). Only two early embolic recurrences (< 24h) occurred, both in the IVT group. There was a 4.8-fold decrease in the median NIHSS score between baseline and 24h follow-up in the intervention group (P<0.0001), and the two groups exhibited similar six-month mortality. At stroke onset, cardiopathy was known in 70% of patients, while LVT was known in 30%. CONCLUSION Acute reperfusion therapies seem to be effective in the context of stroke in patients with LVT. However, further studies are needed to support the hypothesis that stroke recurrence might be related to the use of IVT.
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Affiliation(s)
- P Clottes
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France.
| | - T Bochaton
- Service d'urgences cardiologiques et de soins intensifs de cardiologie, hôpital Louis-Pradel, 59, boulevard Pinel, 69500 Bron, France
| | - L Mechtouff
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - L Derex
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - T-H Cho
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - J Fontaine
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - L Rascle
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - Y Berthezène
- Service d'imagerie médicale, 59, boulevard Pinel, 69500 Bron, France
| | - C Amaz
- Centre d'investigations cliniques, hôpital Louis-Pradel, 59, boulevard Pinel, 69500 Bron, France
| | - H Thibault
- Service des explorations fonctionnelles cardiovasculaires, hôpital Louis-Pradel, 59, boulevard Pinel, 69500 Bron, France
| | - C Bergerot
- Service des explorations fonctionnelles cardiovasculaires, hôpital Louis-Pradel, 59, boulevard Pinel, 69500 Bron, France
| | - N Nighoghossian
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - E Ong
- Service de neurologie vasculaire, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
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7
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Weberling LD, Seitz S, Salatzki J, Ochs A, Heins J, Haney AC, Siry D, Frey N, André F, Steen H. Safety of dobutamine or adenosine stress cardiac magnetic resonance imaging in patients with left ventricular thrombus. Clin Res Cardiol 2024; 113:446-455. [PMID: 37843560 PMCID: PMC10881726 DOI: 10.1007/s00392-023-02317-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Left ventricular (LV) thrombus formation is a common but potentially serious complication, typically occurring after myocardial infarction. Due to perceived high thromboembolic risk and lack of safety data, stress cardiac magnetic resonance (CMR) imaging especially with dobutamine is usually avoided despite its high diagnostic yield. This study aimed to investigate the characteristics, safety and outcome of patients with LV thrombus undergoing dobutamine or vasodilator stress CMR. METHODS Patients undergoing stress CMR with concomitant LV thrombus were retrospectively included. Risk factors, comorbidities, and previous embolic events were recorded. Periprocedural safety was assessed for up to 48 h following the examination. Major adverse cardiac events (MACE) 12 months before the diagnosis were compared to 12 months after the exam and between patients and a matched control group. Additionally, patients were followed up for all-cause mortality. RESULTS 95 patients (78 male, 65 ± 10.7 years) were included. Among them, 43 patients underwent dobutamine (36 high-dose, 7 low-dose) and 52 vasodilator stress CMR. Periprocedural safety was excellent with no adverse events. During a period of 24 months, 27 MACE (14.7%) occurred in patients and controls with no statistical difference between groups. During a median follow-up of 33.7 months (IQR 37.6 months), 6 deaths (6.3%) occurred. Type of stress agent, thrombus mobility, or protrusion were not correlated to embolic events or death. CONCLUSION The addition of a stress test to a CMR exam is safe and does increase the generally high cardioembolic event rate in LV thrombus patients. Therefore, it is useful to support reperfusion decision-making.
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Affiliation(s)
- Lukas D Weberling
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany.
| | | | - Janek Salatzki
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Andreas Ochs
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Jannick Heins
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Ailís C Haney
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Deborah Siry
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Florian André
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Henning Steen
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Puymirat E, Soulat G, Fayol A, Mousseaux E, Montalescot G, Cayla G, Steg PG, Berard L, Rousseau A, Drouet É, Simon T, Danchin N. Rationale and design of the direct oral anticoagulants for prevention of left ventricular thrombus after anterior acute myocardial infarction (APERITIF) trial. Am Heart J 2023; 266:98-105. [PMID: 37716448 DOI: 10.1016/j.ahj.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Anterior acute myocardial infarction (AMI) is associated with an increased risk of left ventricular (LV) thrombus formation. We hypothesized that adding low-dose oral rivaroxaban to the usual antiplatelet regimen would reduce the risk of LV thrombus in patients with large AMI. STUDY DESIGN APERITIF is an investigator-initiated, multicenter randomized open-label, blinded end-point (PROBE) trial, nested in the ongoing "FRENCHIE" registry, a French multicenter prospective observational study, in which all consecutive patients admitted within 48 hours of symptom onset in a cardiac Intensive Care Unit (ICU) for AMI are included (NCT04050956). Among them, patients with anterior ST-elevation-myocardial infarction (STEMI) or very high-risk non- ST-elevation-myocardial infarction (NSTEMI) patients with involvement of the left anterior descending artery are randomized into 2 groups: Dual Antiplatelet Therapy (DAPT) alone or DAPT plus rivaroxaban 2.5mg twice daily for 4 weeks, started as soon as possible after completion of the initial percutaneous coronary intervention/angiography procedure. The primary endpoint is the presence of LV thrombus at 1 month, as detected by contrast enhanced CMR (CE-CMR). Secondary endpoints include LV thrombus dimension (greatest diameter), the rate of major bleedings and major cardiovascular events at 1 month. Based on estimated event rates, a sample size of 560 patients is needed to show superiority of DAPT plus rivaroxaban therapy versus DAPT alone, with 80% power. CONCLUSION The APERITIF trial will determine whether, in patients with large AMIs, the use of rivaroxaban 2.5mg twice daily in addition to DAPT reduces LV thrombus formation, compared with DAPT alone. CLINICALTRIALS gov Identifier: NCT05077683.
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Affiliation(s)
- Etienne Puymirat
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France; PARCC (Paris-Cardiovascular Research Center), INSERM 970, Paris, France; French Alliance for Cardiovascular Trials (FACT), Paris, France.
| | - Gilles Soulat
- PARCC (Paris-Cardiovascular Research Center), INSERM 970, Paris, France; Department of Radiology, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Antoine Fayol
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France; PARCC (Paris-Cardiovascular Research Center), INSERM 970, Paris, France
| | - Elie Mousseaux
- PARCC (Paris-Cardiovascular Research Center), INSERM 970, Paris, France; Department of Radiology, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie (APHP), INSERM UMRS 1166, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Philippe Gabriel Steg
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Université Paris-Cité, INSERM Unité-1148, and Hôpital Bichat, AP-HP, Paris, France
| | - Laurence Berard
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Department of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Alexandra Rousseau
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Department of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Élodie Drouet
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Department of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Tabassome Simon
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Department of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Nicolas Danchin
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France; French Alliance for Cardiovascular Trials (FACT), Paris, France
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9
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He F, Jiao Y, Jiang L. Case report: hunting the hidden: surgical treatment of chronic silent thrombus in the left ventricle in a young alcoholic patient with myocardial bridging. J Cardiothorac Surg 2023; 18:308. [PMID: 37946252 PMCID: PMC10637006 DOI: 10.1186/s13019-023-02414-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND A silent left ventricular thrombus is dangerous. The current standard anticoagulation therapy was ineffective in our case or similar, and the outcome was poor. CASE PRESENTATION A 33-year-old man with a silent left ventricular thrombus was detected incidentally by transthoracic echocardiography. After admission, anti-coagulation with low-molecular-weight heparin therapy was carried out. The CAG revealed 70% systolic stenosis in the middle of the right coronary artery along with myocardial bridging. Unfortunately, an acute left temporal embolism emerged 5 days later, then the patient was transferred to the neurology department for further treatment. One month later, the patient underwent left ventricular thrombectomy, ventricular aneurysm resection, and coronary artery bypass grafting (CABG) and was discharged uneventfully after surgery. CONCLUSIONS Surgical treatment should be a priority for patients with giant or hypermobile left ventricular thrombus or recurrent systemic emboli.
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Affiliation(s)
- Fengpu He
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 67 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Yiping Jiao
- Psychological Teaching and Research Department, Non-commissioned Officer Academy of PAP, Hangzhou, China
| | - Lijun Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 67 Qingchun Road, Hangzhou, 310003, Zhejiang, China.
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10
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Zhang Q, Zhang Z, Zheng H, Wang C, Yu M, Si D, Zhang W. Clinical profile and prognosis of elderly patients with left ventricular thrombus after anticoagulation. Thromb J 2023; 21:75. [PMID: 37430265 PMCID: PMC10332057 DOI: 10.1186/s12959-023-00520-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/01/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Contemporary data regarding the clinical characteristics and prognosis of left ventricular thrombus (LVT) in older adults (aged ≥ 65 years old) are lacking. In this study, we characterized elderly patients with LVT (aged ≥ 65 years old) and investigated the long-term prognosis in this highly vulnerable patient population. METHODS This single-center, retrospective study was conducted from January 2017 to December 2022. Patients with a reported LVT were assessed primarily by transthoracic echocardiography (TEE) and classified into two groups: elderly LVT groups and younger LVT groups. All patients were treated with anticoagulant treatment. Major adverse cardiovascular event (MACE) was defined as the composite of all-cause mortality, systemic embolism, and rehospitalization for cardiovascular events. Survival analyses were performed with the Kaplan-Meier method and Cox proportional-hazard model. RESULTS A total of 315 eligible patients were included. Compared to the younger LVT group (n = 171), the elderly LVT group (n = 144) had a lower proportion of males and lower serum creatinine clearance, as well as a higher level of NT-proBNP, and a higher rate of history of systemic embolism. LVT resolution occurred in 59.7% and 69.0% of patients in the elderly LVT group and younger LVT group, respectively, with no significant difference (adjusted HR, 0.97; 95% CI, 0.74-1.28; P = 0.836). Yet, elderly patients with LVT, had higher prevalence rates of MACE (adjusted HR, 1.52; 95% CI, 1.10-2.11; P = 0.012), systemic embolism (adjusted HR, 2.81; 95% CI, 1.20-6.59; P = 0.017) and all-cause mortality (adjusted HR, 2.20; 95% CI, 1.29-3.74; P = 0.004) compared with younger patients with LVT. After adjusting for mortality in the Fine-Gray model, similar results were observed. Additionally, patients treated with different anticoagulation therapies (DOACs vs. warfarin) achieved a similar improvement in prognosis (P > 0.05) or LVT resolution (P > 0.05) in elderly patients with LVT. CONCLUSIONS Our results found that elderly patients experiencing LVT have a poor prognosis compared with the younger ones. Clinical prognosis in elderly patients did not significantly differ with the type of anticoagulant used. With aging societies worldwide, further evidence of antithrombotic therapy in elderly individuals with LVT is necessary.
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Affiliation(s)
- Qian Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China
| | - Zhongfan Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China
| | - Haikuo Zheng
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China
| | - Chengbing Wang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Changchun, Jilin, China
| | - Miao Yu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China
| | - Daoyuan Si
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China.
| | - Wenqi Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO. 126, 130000, Changchun, Jilin, China.
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11
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Goh FQ, Sia CH, Chan MY, Yeo LL, Tan BY. What's the optimal duration of anticoagulation in patients with left ventricular thrombus? Expert Rev Cardiovasc Ther 2023; 21:947-961. [PMID: 37830297 DOI: 10.1080/14779072.2023.2270906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/11/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Left ventricular thrombus (LVT) occurs in acute myocardial infarction and in ischemic and non-ischemic cardiomyopathies. LVT may result in embolic stroke. Currently, the duration of anticoagulation for LVT is unclear. This is an important clinical question as prolonged anticoagulation is associated with increased bleeding risks, while premature discontinuation may result in embolic complications. AREAS COVERED There are no randomized trial data regarding anticoagulation duration for LVT. Guidelines and expert consensus recommend anticoagulation for 3-6 months with cessation of anticoagulation if interval imaging demonstrates thrombus resolution. Cardiac magnetic resonance imaging (CMR) is more sensitive and specific compared to echocardiography for LVT detection, and may be appropriate for high-risk patients. Prolonged anticoagulation may be considered in unresolved protuberant or mobile LVT, and in patients with resolved LVT but persistent depressed left ventricular ejection fraction and/or myocardial akinesia or dyskinesia. EXPERT OPINION CMR will likely be increasingly used for LVT surveillance to guide anticoagulation duration. Further research is needed to determine which patients with persistent LVT on CMR benefit from prolonged anticoagulation.
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Affiliation(s)
- Fang Qin Goh
- Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark Y Chan
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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12
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Feldman JM, Frishman WH, Aronow WS. Review of the Etiology, Diagnosis, and Management of Left Ventricular Thrombus. Cardiol Rev 2023; Publish Ahead of Print:00045415-990000000-00114. [PMID: 37326429 DOI: 10.1097/crd.0000000000000572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The incidence of left ventricular (LV) thrombus following acute myocardial infarction has declined significantly due to recent advancements in reperfusion and antithrombotic therapies. The development of LV thrombus depends on Virchow's triad: endothelial injury following myocardial infarction, blood stasis from LV dysfunction, and hypercoagulability. Diagnostic modalities for LV thrombus include transthoracic echocardiography and late gadolinium enhancement cardiac magnetic resonance imaging. Anticoagulation with direct oral anticoagulants or vitamin K antagonists for 3 months following initial diagnosis of LV thrombus remains the treatment of choice for LV thrombus. However, further evidence is needed to demonstrate the noninferiority of direct oral anticoagulants compared with vitamin K antagonists for the prevention of thromboembolic events.
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Affiliation(s)
- Jared M Feldman
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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13
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Suzuki T, Fujino M, Murai K, Iwai T, Sawada K, Matama H, Miura H, Honda S, Yoneda S, Takagi K, Otsuka F, Asaumi Y, Kataoka Y, Tahara Y, Ogata S, Nishimura K, Tsujita K, Noguchi T. Urinary catheterization prior to PCI worsens clinical outcomes in patients with acute myocardial infarction. J Cardiol 2023; 81:373-377. [PMID: 36565996 DOI: 10.1016/j.jjcc.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Indwelling urethral catheters (IUCs) are used to measure urine volume, keep patients on bed rest, or keep the groin area clean in patients with acute myocardial infarction (AMI). However, the association between IUC use and in-hospital urinary-related complications is unknown. METHODS This was a single-center retrospective analysis of 303 patients admitted to our hospital in 2018-2020 who had AMI without cardiogenic shock. An IUC was inserted in the emergency room upon initiation of invasive catheter treatment and removed as soon as possible. The primary outcome was in-hospital adverse urinary event (IHAUE), which consisted of in-hospital urinary tract infection and in-hospital gross hematuria. RESULTS Of 303 patients, 243 patients (80.2 %) underwent IUC insertion. A lower proportion of patients with IUCs were male (72 % vs. 85 %, p = 0.044). A higher proportion had Killip classification 2 or 3 (13 % vs. 0 %, p = 0.003) or ST-elevation myocardial infarction (65 % vs. 32 %, p < 0.001). IHAUEs occurred significantly more commonly in patients with IUCs than without IUCs (11 % vs. 2 %, p = 0.023). Kaplan-Meier analysis showed that IHAUEs occurred more frequently in patients with IUCs than patients without IUCs (log-rank test p = 0.033). Furthermore, IUC use longer than the median of 2 days was associated with a higher odds ratio (OR) for IHAUE when compared with those without IUC use (OR, 3.65; 95 % confidence interval, 1.28-10.4; p = 0.015). There were no significant differences in in-hospital mortality by IUC status. CONCLUSIONS IUC use is associated with a higher risk of IHAUEs in patients with uncomplicated AMI. Routine IUC use might not be recommended.
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Affiliation(s)
- Toshiaki Suzuki
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masashi Fujino
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan.
| | - Kota Murai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takamasa Iwai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hideo Matama
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Shuichi Yoneda
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Kensuke Takagi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Soshiro Ogata
- Department of Clinical Research and Development, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Kunihiro Nishimura
- Department of Clinical Research and Development, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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14
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Bayam E, Çakmak EÖ, Yıldırım E, Kalçık M, Bilen Y, Güner A, Küp A, Kahyaoğlu M, Çelik M, Öcal L, Avcı A, Zehir R. The relationship between CHA2DS2VASc score and left ventricular apical thrombus formation in patients with acute anterior ST segment elevation myocardial infarction. Acta Cardiol 2023; 78:24-31. [PMID: 34714216 DOI: 10.1080/00015385.2021.1991667] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Left ventricular apical thrombus (LVAT) formation is a well-known complication of acute anterior myocardial infarction (AMI). The CHA2DS2VASc is a scoring system that has been used to estimate the risk of thromboembolism in patients with nonvalvular atrial fibrillation. This score has also been used for other clinical conditions. The aim of this study was to investigate the relationship between CHA2DS2VASc score and development of LVAT in patients with AMI. METHOD The study population included 378 patients (mean age: 56.5 ± 12.3 years, male: 318) presenting with AMI between January 2016 and January 2020. Primary percutaneous coronary intervention procedure was performed in all patients. Initial echocardiogram was performed within 7 days of admission. All patients were evaluated with echocardiography at 3rd, 6th and 12th months. Patients were divided into two groups according to the presence of LVAT on echocardiography. RESULTS The incidence of the LVAT was 8.5% (n = 32) during a mean follow-up time of 233.1 ± 66.7 days. The mean CHA2DS2VASc score was notably higher in patients with LVAT compared to patients in the control group (3.1 ± 1.9 vs. 1.9 ± 1.2, p < 0.001). In Cox regression analysis, high CHA2DS2VASc score, low left ventricular ejection fraction (LVEF) and the presence of LV apical akinesis/aneurysm were the independent predictors for LVAT formation. All of these parameters were associated with higher cumulative incidence of LVAT formation in Kaplan-Meier analyses (p < 0.001 for all). CONCLUSION High CHA2DS2VASc score, low LVEF and the presence of LV apical akinesis/aneurysm may be used for LVAT risk prediction among patients presenting with AMI.
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Affiliation(s)
- Emrah Bayam
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Ender Özgün Çakmak
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Ersin Yıldırım
- Depertament of Cardiology, University of Medical Sciences, Umraniye Training and Research Hospital, İstanbul, Turkey
| | - Macit Kalçık
- Depertament of Cardiology, Hitit University, Faculty of Medicine, Çorum, Turkey
| | - Yusuf Bilen
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ayhan Küp
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Muzaffer Kahyaoğlu
- Department of Cardiology, Abdülkadir Yüksel State Hospital, Gaziantep, Turkey
| | - Mehmet Çelik
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Lütfi Öcal
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Anıl Avcı
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Regayip Zehir
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
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15
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Anticoagulation for Left Ventricle Thrombus-Case Series and Literature Review for Use of Direct Oral Anticoagulants. J Cardiovasc Dev Dis 2023; 10:jcdd10020041. [PMID: 36826537 PMCID: PMC9962157 DOI: 10.3390/jcdd10020041] [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: 12/03/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
Left ventricular thrombus is a known complication following acute myocardial infarction that can lead to systemic thromboembolism. To obviate the risk of thromboembolism, the patient needs anticoagulation in addition to dual antiplatelet therapy. However, combining antiplatelets with anticoagulants substantially increases the bleeding risk. Traditionally, vitamin K antagonists (VKAs) have been the sheet anchor for anticoagulation in this scenario. The use of direct oral anticoagulants has significantly attenuated the bleeding risk associated with anticoagulation for atrial fibrillation and venous thromboembolism. Furthermore, in patients with atrial fibrillation undergoing percutaneous coronary intervention, the use of direct oral anticoagulants (DOACs) in conjunction with antiplatelets has been found to be noninferior in reducing ischemic events while significantly attenuating the bleeding compared with VKA. After initial case reports, multiple observational and nonrandomized studies have now safely and effectively utilized direct oral anticoagulants for anticoagulation in left ventricular thrombus. Here, we report a series of two cases presenting with left ventricular thrombus following acute myocardial infarction. In this case series, we try to address the issues concerning the choice and duration of anticoagulation in the case of postinfarct left ventricular thrombus. Pending the results of large randomized control trials, the judicious use of direct oral anticoagulant is warranted when taking into consideration the ischemic and bleeding profile in an individualized approach.
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16
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Contemporary incidence and predictors of left ventricular thrombus in patients with anterior acute myocardial infarction. Clin Res Cardiol 2023; 112:558-565. [PMID: 36651998 DOI: 10.1007/s00392-023-02158-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The incidence of left ventricular thrombus (LVT) after anterior acute myocardial infarction (AMI) has not been well established in the era of primary percutaneous coronary intervention (pPCI) and potent dual antiplatelet therapy. The objective of this study is to establish the contemporary incidence of LVT in this population, to identify their risk factors, and to examine their association with clinical outcomes. METHODS A multicenter retrospective cohort study including AMI patients with new-onset antero-apical wall motion abnormalities treated with pPCI between 2009 and 2017 was conducted. The primary outcome was LVT during the index hospitalization. Predictors of LVT were identified using multivariate logistic regression. Net adverse clinical events (NACE), a composite of mortality, myocardial infarction, stroke or transient ischemic attack, systemic thromboembolism or BARC type 3 or 5 bleeding at 6 months were compared between the LVT and no LVT groups. RESULTS Among the 2136 patients included, 83 (3.9%) patients developed a LVT during index hospitalization. A lower left ventricular ejection fraction (LVEF) [adjusted odds ratio (aOR) 0.97; 95% confidence intervals (CI) 0.94-0.99] and the degree of worse anterior WMA (aOR 4.34; 95% CI 2.24-8.40) were independent predictors of LVT. A NACE occurred in 5 (5.72 per 100 patient-year) patients in the LVT group and in 127 (6.71 per 100 patient-year) patients in the no LVT group at 6 months [adjusted hazard ratio (aHR): 0.87; 95% CI 0.35-2.14]. CONCLUSIONS The risk of LVT after anterior AMI with new-onset wall motion abnormalities is low, but this complication remains present in the contemporary era of timely pPCI and potent dual antiplatelet therapy .
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Badescu MC, Sorodoc V, Lionte C, Ouatu A, Haliga RE, Costache AD, Buliga-Finis ON, Simon I, Sorodoc L, Costache II, Rezus C. Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus. J Pers Med 2023; 13:jpm13010158. [PMID: 36675819 PMCID: PMC9866081 DOI: 10.3390/jpm13010158] [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: 12/01/2022] [Revised: 12/17/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
In recent years, direct oral anticoagulants (DOAC) have accumulated evidence of efficacy and safety in various clinical scenarios and are approved for a wide spectrum of indications. Still, they are currently used off-label for left ventricular thrombus owing to a paucity of evidence. For the same reason, there is a lack of guideline indication as well. Our work is based on an exhaustive analysis of the available literature and provides a structured and detailed update on the use of DOACs in patients with left ventricle thrombus. The safety and efficacy of DOACs were analyzed in particular clinical scenarios. As far as we know, this is the first paper that analyzes DOACs in this approach.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Victorita Sorodoc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
- Correspondence: (V.S.); (C.L.)
| | - Catalina Lionte
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
- Correspondence: (V.S.); (C.L.)
| | - Anca Ouatu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Raluca Ecaterina Haliga
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Alexandru Dan Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiovascular Rehabilitation Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ioan Simon
- Department of Surgery, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Laurentiu Sorodoc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
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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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20
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Zhu C, Zhou L, Gao H, Wang J, Li J, Chen H, Li H. Case report: Oral anticoagulant combined with percutaneous coronary intervention for peripheral embolization of left ventricular thrombus caused by myocardial infarction in a patient with diabetes mellitus. Front Cardiovasc Med 2022; 9:1019945. [PMID: 36568554 PMCID: PMC9775277 DOI: 10.3389/fcvm.2022.1019945] [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: 08/15/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Background Left ventricular thrombus (LVT) is a well-recognized complication of myocardial infarction (MI) in patients with diabetes. An embolic complication caused by LVT is a key clinical problem and is associated with worsened long-term survival. Case presentation A 45-year-old man with persistent left abdominal pain for 1 week and left leg fatigue was admitted to the emergency department. The cause of abdominal pain was embolism of the renal artery, the splenic artery, and the superior mesenteric artery caused by cardiogenic thrombosis, which further led to splenic infarction and renal infarction. It was unclear when MI occurred because the patient had no typical critical chest pain, which may have been related to diabetic complications, such as diabetic peripheral neuropathy. Diabetes plays a pivotal role in MI and LVT formation. Because coronary angiography suggested triple vessel disease, percutaneous transluminal coronary angioplasty (PTCA) was conducted, and two drug-eluting stents were placed in the left anterior descending coronary artery (LAD). Due to a lack of randomized clinical control trials, the therapy of LVT and associated embolization has been actively debated. According to the present guidelines, this patient was treated with low-molecular-weight heparin and warfarin (oral anticoagulants) for 3 months in addition to aspirin (100 mg/day) and clopidogrel (75 mg/day) for 1 year. No serious bleeding complications were noted, and a follow-up examination showed no thrombus in the left ventricle or further peripheral thrombotic events. Conclusion Peripheral embolization of LVT caused by MI leading to multiple organ embolization remains a rare occurrence. Diabetes plays a pivotal role in MI and LVT formation. Successful revascularization of the infarct-related coronary artery and anticoagulation therapy is important to minimize myocardial damage and prevent LVT. The present case will help clinicians recognize and manage LVT in patients with diabetes and related peripheral arterial thrombotic events with anticoagulation.
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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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Ohte N, Ishizu T, Izumi C, Itoh H, Iwanaga S, Okura H, Otsuji Y, Sakata Y, Shibata T, Shinke T, Seo Y, Daimon M, Takeuchi M, Tanabe K, Nakatani S, Nii M, Nishigami K, Hozumi T, Yasukochi S, Yamada H, Yamamoto K, Izumo M, Inoue K, Iwano H, Okada A, Kataoka A, Kaji S, Kusunose K, Goda A, Takeda Y, Tanaka H, Dohi K, Hamaguchi H, Fukuta H, Yamada S, Watanabe N, Akaishi M, Akasaka T, Kimura T, Kosuge M, Masuyama T. JCS 2021 Guideline on the Clinical Application of Echocardiography. Circ J 2022; 86:2045-2119. [DOI: 10.1253/circj.cj-22-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | | | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroshi Itoh
- Department of Cardiovascular Medicine, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Science
| | - Shiro Iwanaga
- Department of Cardiology, Saitama Medical University International Medical Center
| | - Hiroyuki Okura
- Department of Cardiology, Gifu University Graduate School of Medicine
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- The Department of Clinical Laboratory, The University of Tokyo Hospital
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health
| | - Kazuaki Tanabe
- The Fourth Department of Internal Medicine, Shimane University Faculty of Medicine
| | | | - Masaki Nii
- Department of Cardiology, Shizuoka Children's Hospital
| | - Kazuhiro Nishigami
- Division of Cardiovascular Medicine, Miyuki Hospital LTAC Heart Failure Center
| | - Takeshi Hozumi
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Heart Center, Nagano Children’s Hospital
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences
| | - Kazuhiro Yamamoto
- Department of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Katsuji Inoue
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | | | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Akiko Goda
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Yasuharu Takeda
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | | | - Hidekatsu Fukuta
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences
| | - Satoshi Yamada
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | | | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
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24
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Liang J, Wang Z, Zhou Y, Shen H, Chai M, Ma X, Han H, Shao Q, Li Q. Efficacy and Safety of Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus After Acute Anterior Myocardial Infarction in Patients Who Underwent Percutaneous Coronary Intervention. Curr Vasc Pharmacol 2022; 20:517-526. [PMID: 36200193 DOI: 10.2174/1570161120666221003104821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
AIMS To explore treatment with Direct Oral Anticoagulants (DOACs) in left ventricular thrombus (LVT) after ST-segment elevation myocardial infarction (STEMI) in patients who underwent percutaneous coronary intervention (PCI). BACKGROUND Contemporary data regarding using DOACs for LVT after STEMI patients who underwent PCI is limited. OBJECTIVES To investigate the efficacy and safety of DOACs on the treatment of LVT post STEMI and PCI. METHODS This retrospective study enrolled patients with LVT post STEMI and PCI within 1month from onset who received warfarin or DOACs at discharge. The primary endpoint was LVT resolution. Secondary endpoints were major adverse cardiovascular events (MACEs), including death, stroke, systemic embolism (SE), myocardial infarction (MI) and major or minor bleeding. RESULTS A total of 128 consecutive patients were recruited, of which 72 received warfarin and 56 DOACs [48 on rivaroxaban and 8 on dabigatran]. The rate of LVT resolution was higher within 1 month in the DOACs group than warfarin (26.8% vs. 11.1%; p = 0.022) (Kaplan-Meier estimates, p = 0.002). No significant differences were found at 3 months (p = 0.246), 6 months (p = 0.201), 9 months (p = 0.171) and 12 months (p = 0.442). No patients treated with DOACs had major bleeding, while two patients with warfarin had upper gastrointestinal bleeding (0 vs. 2 (2.8%); p = 0.209). No death or SE occurred. No significant differences on secondary endpoints were found in both the groups, including stroke, MI, minor bleeding and all bleeding events. CONCLUSION DOACs appear to be a suitable alternative to warfarin for the management of LVT post STEMI, especially in patients who are intolerant to warfarin.
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Affiliation(s)
- Jing Liang
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Zhijian Wang
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Hua Shen
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Meng Chai
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Xiaoteng Ma
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Hongya Han
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Qiaoyu Shao
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Qiuxuan Li
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
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25
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Evidence-Based Recommendations: Management of Left Ventricular Thrombus Post-Acute Myocardial Infarction. Dimens Crit Care Nurs 2022; 41:313-320. [PMID: 36179309 DOI: 10.1097/dcc.0000000000000553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
One of the potential complications of acute myocardial infarction is left ventricular thrombus (LVT). The incidence of LVT following acute myocardial infarction has decreased dramatically with early invasive reperfusion techniques or fibrinolysis. However, the risk of LVT formation remains significant and is associated with an increased risk of systemic embolism, stroke, cardiovascular events, and even death. Current guidelines indicate that dual antiplatelet therapy and anticoagulation therapy for at least 3 months can reduce the risk of these events. While vitamin K antagonist is the preferred oral anticoagulant, there is growing evidence to support the use of direct-acting oral anticoagulants in LVT management. Cardiac magnetic resonance has shown the highest diagnostic accuracy for LVT assessment, followed by echocardiography with contrast agents. This article serves as a general review of the pathophysiology, diagnosis, and management of LVT.
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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: 62] [Impact Index Per Article: 31.0] [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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Lorente-Ros Á, Alonso-Salinas GL, Monteagudo Ruiz JM, Abellás-Sequeiros M, Vieítez-Florez JM, Sánchez Vega D, Álvarez-Garcia J, Sanmartín-Fernández M, Lorente-Ros M, del Prado Díaz S, Fernández Golfín C, Zamorano Gómez JL. Effect of Duration of Anticoagulation in the Incidence of Stroke in Patients With Left-Ventricular Thrombus. Am J Cardiol 2022; 185:115-121. [PMID: 36243566 DOI: 10.1016/j.amjcard.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/15/2022] [Accepted: 09/08/2022] [Indexed: 11/25/2022]
Abstract
The optimal duration of anticoagulation in patients with left-ventricular thrombus (LVT) is unclear. In the present study, we aimed to analyze the effect of treatment duration (≤12 months [short-term anticoagulation, (STA)] versus >12 months [long-term anticoagulation, (LTA)]) in the incidence of stroke and other secondary outcomes (acute myocardial infarction, bleeding, and mortality). Multivariate Cox regression was used to determine the association between treatment duration and stroke, adjusted for baseline embolic risk. A total of 98 cases of LVT (age 64.3 ± 12.8 years, female 18 [18%]) were identified. Sixty-one patients (62%) received LTA. Patients receiving LTA were older than those receiving STA (66.5 ± 11.6 vs 60.7 ± 13.9 years, p = 0.029), more often had atrial fibrillation (31% vs 0%, p <0.001), and had a higher CHA2DS2-VASc score (4.3 ± 1.6 vs 3.6 ± 1.6, p = 0.046). Stroke occurred in 2 and 10 patients (3% vs 27%, p <0.001), acute myocardial infarction in 2 and 3 patients (3% vs 8%, p = 0.292), bleeding in 4 and 3 patients (7% vs 8%, p = 0.773), and mortality in 12 and 7 patients (20% vs 19%, p = 0.927) in the LTA and STA groups, respectively. In multivariate analysis, after adjusting for embolic risk, LTA was associated with decreased risk of stroke at 5 years (adjusted hazard ratio 0.16; 95% confidence interval 0.03 to 0.72, p = 0.017). In conclusion, our data suggest that prolonged anticoagulation in patients with LVT may be associated with significantly lower risk of stroke.
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28
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Shi B, Zhang R, Song C, Cui K, Zhang D, Dong Q, Jia L, Yin D, Wang H, Dou KF, Song W. Novel subgroups of patients with left ventricular thrombus and their differential effects with anticoagulation: a data-driven cluster analysis (Preprint). J Med Internet Res 2022. [PMID: 36446627 DOI: 10.2196/42909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
UNSTRUCTURED Ahead of Print article withdrawn by the publisher.
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Affiliation(s)
- Boqun Shi
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Rui Zhang
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Chenxi Song
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Kongyong Cui
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Dong Zhang
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Qiuting Dong
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Lei Jia
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Dong Yin
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Hongjian Wang
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Ke-Fei Dou
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
| | - Weihua Song
- Cardiometabolic Medicine Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, No.167 North Lishi Road, Xicheng District, Beijing, CN
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, CN
- State Key Laboratory of Cardiovascular Disease, Beijing, CN
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29
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Li C, Lau W, Qian N, Song L, Jin C, Zhou D, Yu Y, Pan X, Zhou Q. Clinical characteristics and prognosis of patients with left ventricular thrombus in East China. Front Cardiovasc Med 2022; 9:944687. [PMID: 36158827 PMCID: PMC9492992 DOI: 10.3389/fcvm.2022.944687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Left ventricular thrombus (LVT) is a serious complication in patients with left ventricular dysfunction. However, there is still a paucity of data on treatments and prognosis of patients with LVT. This study aims to evaluate the clinical characteristics of patients with LVT and to determine the impact of LVT on the incidence of major adverse cardiovascular events (MACEs) and all-cause mortality. Methods From January 2010 to January 2020, 237 patients diagnosed with LVT at The Second Affiliated Hospital Zhejiang University School of Medicine in East China were retrospectively included. Clinical characteristics, treatments, MACEs, and bleeding events [thrombolysis in myocardial infarction (TIMI) I and II] were collected. MACE is determined as the composite of all-cause mortality, ischemic stroke, acute myocardial infarction (MI), and acute peripheral artery emboli. Results The all-cause mortality rate was 28.3% (89.6% due to cardiovascular death), ischemic stroke 8.4%, MI 3%, peripheral artery emboli 1.7%, and bleeding events (TIMI I and II) 7.6% were found during a median follow-up of 736 days. Total LVT regression occurred in 152 patients (64.1%). Atrial fibrillation [hazard ratio (HR), 3.049; 95% confidence interval (95% CI) 1.264–7.355; p = 0.013], moderate and severe renal function injuries (HR, 2.097; 95% CI, 1.027–4.281; p = 0.042), and left ventricular ejection fraction (LVEF) ≤ 50% (HR, 2.243; 95% CI 1.090–4.615; p = 0.028) were independent risk factors for MACE, whereas the use of β-blocker (HR, 0.397; 95% CI 0.210–0.753; p = 0.005) was its protective factor. Age (HR, 1.021; 95% CI 1.002–1.040; p = 0.031), previous caronary artery bypass grafting (CABG; HR, 4.634; 95% CI 2.042–10.517; p < 0.001), LVEF ≤ 50% (HR, 3.714; 95% CI 1.664–8.290; p = 0.001), and large thrombus area (HR, 1.071; 95% CI 1.019–1.126; p = 0.007) were independent risk factors for increasing all-cause mortality, whereas the use of β-blocker (HR, 0.410; 95% CI 0.237–0.708; p = 0.001) was protective factor. Conclusion This study showed that atrial fibrillation, moderate and severe renal dysfunction, and LVEF ≤ 50% were independent risk factors for MACE; age, previous CABG, LVEF ≤ 50%, and large thrombus area were independent risk factors for all-cause mortality. It was found that the use of β-blockers could improve the prognosis of patient with LVT for the first time. It is recommended that clinicians could be more active in applying patient with LVT with anticoagulants.
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Affiliation(s)
- Cheng Li
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wenjie Lau
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ningjing Qian
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Liuguang Song
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chunna Jin
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Dao Zhou
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi Yu
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaohong Pan
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Xiaohong Pan,
| | - Quan Zhou
- Department of Pharmacy, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Quan Zhou,
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Allard L, Bernhard B, Windecker S, Valgimigli M, Gräni C. Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:496-509. [PMID: 34928322 DOI: 10.1093/ehjqcco/qcab097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 12/29/2022]
Abstract
Although the management of ischaemic heart disease has markedly improved over the last decades, left ventricular thrombus remains a serious finding in patients with myocardial infarction. Routine diagnostic detection of left ventricular thrombus relies mainly on echocardiography; however, cardiac magnetic resonance has emerged as a method with higher diagnostic accuracy, while cardiac computed tomography angiography represents a valuable alternative modality. To reduce the left ventricular thrombus-associated morbidity and mortality, optimal selection of anticoagulation is warranted after balancing the risk of bleeding. In this review, we will discuss contemporary diagnostic modalities to detect left ventricular thrombus in ischaemic heart disease and summarize evidence on risk stratification and therapy. In addition, we propose a novel diagnosis, follow-up imaging, and treatment algorithm. Further, we identify knowledge gaps at different levels to address emerging research questions and to refine the design of future studies aiming to improve the management of patients in this clinical setting.
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Affiliation(s)
- Ludovic Allard
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.,Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale and Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | - Christoph Gräni
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
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Ma S, Bai L, Liu P, She G, Deng XL, Song AQ, Du XJ, Lu Q. Pathogenetic Link of Cardiac Rupture and Left Ventricular Thrombus Following Acute Myocardial Infarction: A Joint Preclinical and Clinical Study. Front Cardiovasc Med 2022; 9:858720. [PMID: 35757352 PMCID: PMC9218188 DOI: 10.3389/fcvm.2022.858720] [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: 01/20/2022] [Accepted: 04/25/2022] [Indexed: 12/01/2022] Open
Abstract
Background Cardiac rupture (CR) and left ventricular thrombus (LVT) remain important complications of acute myocardial infarction (MI), and they are currently regarded as independent events. We explored the pathogenetic link between CR and LVT by investigating a murine model of MI with a high frequency of CR and in patients with acute MI. Methods MI was induced in mice, the onset of CR was monitored, and the hearts of mice with or without fatal CR were histologically examined. Between 2015 and 2022, from patients admitted due to acute MI, the data of patients with CR or LVT were retrospectively collected and compared to uncomplicated patients (control). Results A total of 75% of mice (n = 65) with MI developed CR 2–4 days after MI. A histological examination of CR hearts revealed the existence of platelet-rich intramural thrombi in the rupture tunnel, which was connected at the endocardial site to platelet-fibrin thrombi within an LVT. In CR or non-CR mouse hearts, LV blood clots often contained a portion of platelet-fibrin thrombi that adhered to the infarct wall. In non-CR hearts, sites of incomplete CR or erosion of the infarct wall were typically coated with platelet thrombi and dense inflammatory cells. Of 8,936 patients with acute MI, CR and LVT occurred in 102 (1.14%) and 130 (1.45%) patients, respectively, with three cases having both complications. CR accounted for 32.8% of in-hospital deaths. The majority of CR (95%) or LVT (63%, early LVT) occurred within 7 days. In comparison to the control or LVT-late groups, patients with CR or early LVT reported increased levels of cellular and biochemical markers for inflammation or cardiac injury. Conclusion CR and LVT after MI are potentially linked in their pathogenesis. LVT occurring early after MI may be triggered by a thrombo-inflammatory response following wall rupture or endocardial erosion.
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Affiliation(s)
- Shan Ma
- Department of Internal Medicine-Cardiovascular, Cardiovascular Hospital, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Ling Bai
- Department of Internal Medicine-Cardiovascular, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Ping Liu
- Department of Internal Medicine-Cardiovascular, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Gang She
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi’an Jiaotong University, Xi’an, China
| | - Xiu-Ling Deng
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi’an Jiaotong University, Xi’an, China
| | - An-Qi Song
- Department of Internal Medicine-Cardiovascular, Cardiovascular Hospital, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xiao-Jun Du
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi’an Jiaotong University, Xi’an, China
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- *Correspondence: Xiao-Jun Du,
| | - Qun Lu
- Department of Internal Medicine-Cardiovascular, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Qun Lu,
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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: 0] [Impact Index Per Article: 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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Demirkiran A, Hassell MECJ, Garg P, Elbaz MSM, Delewi R, Greenwood JP, Piek JJ, Plein S, van der Geest RJ, Nijveldt R. Left ventricular four-dimensional blood flow distribution, energetics, and vorticity in chronic myocardial infarction patients with/without left ventricular thrombus. Eur J Radiol 2022; 150:110233. [PMID: 35278980 DOI: 10.1016/j.ejrad.2022.110233] [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: 06/03/2021] [Revised: 02/23/2022] [Accepted: 02/26/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Left ventricular thrombus (LVT) formation is a frequent and serious complication of myocardial infarction (MI). How global LV flow characteristics are related to this phenomenon is yet uncertain. In this study, we investigated LV flow differences using 4D flow cardiovascular magnetic resonance (CMR) between chronic MI patients with LVT [MI-LVT(+)] and without LVT [MI-LVT(-)], and healthy controls. METHODS In this prospective cohort study, the 4D flow CMR data were acquired in 19 chronic MI patients (MI-LVT(+), n = 9 and MI-LVT(-), n = 10) and 9 age-matched controls. All included subjects were in sinus rhythm. The following LV flow parameters were obtained: LV flow components (direct, retained, delayed, residual), mean and peak kinetic energy (KE) values (indexed to instantaneous LV volume), mean and peak vorticity values, and diastolic vortex ring properties (position, orientation, shape). RESULTS The MI patients demonstrated a significantly larger amount of delayed and residual flow, and a smaller amount of direct flow compared to controls (p = 0.02, p = 0.03, and p < 0.001, respectively). The MI-LVT(+) patients demonstrated numerically increased residual flow and reduced retained and direct flow in comparison to MI-LVT(-) patients. Systolic mean and peak LV blood flow KE values were significantly lower in MI patients compared to controls (p = 0.04, p = 0.03, respectively). Overall, the mean and peak LV vorticity values were significantly lower in MI patients compared to controls. The mean and peak systolic vorticity at the basal level were significantly higher in MI-LVT(+) than in MI-LVT(-) patients (p < 0.01, for both). The vortex ring core during E-wave in MI-LVT(+) group was located in a less tilted orientation to the LV compared to MI-LVT(-) group (p < 0.01). CONCLUSIONS Chronic MI patients with LVT express a different distribution of LV flow components, irregular vorticity vector fields, and altered diastolic vortex ring geometric properties as assessed by 4D flow CMR. Larger prospective studies are warranted to further evaluate the significance of these initial observations.
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Affiliation(s)
- Ahmet Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | | | - Pankaj Garg
- Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Mohammed S M Elbaz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Rob J van der Geest
- Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
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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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Pradhan A, Bhandari M, Vishwakarma P, Sethi R. Concurrent coronary, left ventricle, and cerebral thrombosis – A trilogy. Int J Appl Basic Med Res 2022; 12:130-133. [PMID: 35754676 PMCID: PMC9215190 DOI: 10.4103/ijabmr.ijabmr_95_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 02/05/2023] Open
Abstract
Left ventricular (LV) thrombus is a known complication of acute myocardial infarction (AMI), especially anterior wall MI and leads to systemic thromboembolism. However, increase in the rates of coronary perfusion either by thrombolysis or percutaneous interventions have reduced its incidence. Concurrent stroke and MI are seen in 0.009% of cases. The occurrence of AMI with LV thrombus with or without stroke mandates the combination of antiplatelet and antithrombotic therapy. Hitherto, there are no randomized studies in the setting of AMI with LV thrombus comparing dual (single antiplatelet plus oral anticoagulant [OAC]) and triple therapy (dual antiplatelet therapy with OAC). There are no large randomized trials as well to delineate the optimal therapy for simultaneous cardiac and cerebral infarction. We hereby, report an unusual case of a young patient who presented with triple combo of acute anterior wall MI, LV thrombus, and ischemic stroke and discuss the challenges in management in this scenario.
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Chen M, Liu D, Weidemann F, Lengenfelder BD, Ertl G, Hu K, Frantz S, Nordbeck P. Echocardiographic risk factors of left ventricular thrombus in patients with acute anterior myocardial infarction. ESC Heart Fail 2021; 8:5248-5258. [PMID: 34498435 PMCID: PMC8712797 DOI: 10.1002/ehf2.13605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/02/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
AIMS This study aimed to identify echocardiographic determinants of left ventricular thrombus (LVT) formation after acute anterior myocardial infarction (MI). METHODS AND RESULTS This case-control study comprised 55 acute anterior MI patients with LVT as cases and 55 acute anterior MI patients without LVT as controls, who were selected from a cohort of consecutive patients with ischemic heart failure in our hospital. The cases and controls were matched for age, sex, and left ventricular ejection fraction. LVT was detected by routine/contrast echocardiography or cardiac magnetic resonance imaging during the first 3 months following MI. Formation of apical aneurysm after MI was independently associated with LVT formation [72.0% vs. 43.5%, odds ratio (OR) = 5.06, 95% confidence interval (CI) 1.65-15.48, P = 0.005]. Echocardiographic risk factors associated with LVT formation included reduced mitral annular plane systolic excursion (<7 mm, OR = 4.69, 95% CI 1.84-11.95, P = 0.001), moderate-severe diastolic dysfunction (OR = 2.71, 95% CI 1.11-6.57, P = 0.028), and right ventricular (RV) dysfunction [reduced tricuspid annular plane systolic excursion < 17 mm (OR = 5.48, 95% CI 2.12-14.13, P < 0.001), reduced RV fractional area change < 0.35 (OR = 3.32, 95% CI 1.20-9.18, P = 0.021), and enlarged RV mid diameter (per 5 mm increase OR = 1.62, 95% CI 1.12-2.34, P = 0.010)]. Reduced tricuspid annular plane systolic excursion (<17 mm) significantly associated with increased risk of LVT in anterior MI patients (OR = 3.84, 95% CI 1.37-10.75, P = 0.010), especially in those patients without apical aneurysm (OR = 5.12, 95% CI 1.45-18.08, P = 0.011), independent of body mass index, hypertension, anaemia, mitral annular plane systolic excursion, and moderate-severe diastolic dysfunction. CONCLUSIONS Right ventricular dysfunction as determined by reduced TAPSE or RV fractional area change is independently associated with LVT formation in acute anterior MI patients, especially in the setting of MI patients without the formation of an apical aneurysm. This study suggests that besides assessment of left ventricular abnormalities, assessment of concomitant RV dysfunction is of importance on risk stratification of LVT formation in patients with acute anterior MI.
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Affiliation(s)
- Mengjia Chen
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Dan Liu
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Frank Weidemann
- Medizinischen Klinik I des Klinikum VestRecklinghausenGermany
| | - Björn Daniel Lengenfelder
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Georg Ertl
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Kai Hu
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Stefan Frantz
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
| | - Peter Nordbeck
- Department of Internal Medicine IUniversity Hospital WürzburgOberdürrbacher Str. 6WürzburgGermany
- Comprehensive Heart Failure CenterWürzburgGermany
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A ROS-responsive, self-immolative and self-reporting hydrogen sulfide donor with multiple biological activities for the treatment of myocardial infarction. Bioact Mater 2021; 9:168-182. [PMID: 34820564 PMCID: PMC8586025 DOI: 10.1016/j.bioactmat.2021.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/22/2021] [Accepted: 07/09/2021] [Indexed: 12/14/2022] Open
Abstract
Myocardial infarction (MI), as one of the leading causes of global death, urgently needs effective therapies. Recently, hydrogen sulfide (H2S) has been regarded as a promising therapeutic agent for MI, while its spatiotemporally controlled delivery remains a major issue limiting clinical translation. To address this limitation, we designed and synthesized a novel H2S donor (HSD-R) that can produce H2S and emit fluorescence in response to reactive oxygen species (ROS) highly expressed at diseased sites. HSD-R can specifically target mitochondria and provide red fluorescence to visualize and quantify H2S release in vitro and in vivo. Therapeutically, HSD-R significantly promoted the reconstruction of cardiac structure and function in a rat MI model. Mechanistically, myocardial protection is achieved by reducing cardiomyocyte apoptosis, attenuating local inflammation, and promoting angiogenesis. Furthermore, inhibition of typical pro-apoptotic genes (Bid, Apaf-1, and p53) played an important role in the anti-apoptotic effect of HSD-R to achieve cardioprotection, which were identified as new therapeutic targets of H2S against myocardial ischemia injury. This ROS-responsive, self-immolative, and fluorescent H2S donor can serve as a new theranostic agent for MI and other ischemic diseases. A reactive oxygen species-responsive and self-reporting H2S donor (HSD-R) is developed for controlled H2S delivery. HSD-R shows desirable fluorescence for imaging H2S release upon triggering by reactive oxygen species. HSD-R displays significant cardioprotective effects in rats. HSD-R exhibits multiple biological activities including anti-apoptotic, anti-inflammatory, and pro-angiogenic effects. Anti-apoptotic activity of HSD-R is due to inhibiting the expression of several pro-apoptotic factors.
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Hofer F, Kazem N, Schweitzer R, Horvat P, Winter MP, Koller L, Hengstenberg C, Sulzgruber P, Niessner A. The prognostic impact of left ventricular thrombus resolution after acute coronary syndrome and risk modulation via antithrombotic treatment strategies. Clin Cardiol 2021; 44:1692-1699. [PMID: 34664732 PMCID: PMC8715401 DOI: 10.1002/clc.23741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 11/12/2022] Open
Abstract
Background Left ventricular thrombus (LVT) is a rare but dreaded complication during the acute phase of acute coronary syndrome (ACS). However, profound data on long‐term outcome and associated antithrombotic treatment strategies of this highly vulnerable patient population are scarce in current literature. Methods Patients presenting with ACS were screened for presence of LVT and subsequently included within a prospective clinical registry. All‐cause mortality and the composite of major adverse cardiac events (MACE) and thromboembolic events were defined as primary and secondary endpoint. Results Within 43 patients presenting with LVT, thrombus resolution during patient follow‐up was observed in 27 individuals (62.8%). Patients that reached a resolution of LVT experienced lower incidence rates of death (−23.9%; p = .022), MACE (−37.8%; p = .005), and thromboembolic events (−35.2%; p = .008). Even after adjustment for clinical variables, thrombus resolution showed an independent inverse association with all‐cause death with a hazard ratio (HR) of 0.14 (95% CI: 0.03–0.75; p = .021) and as well with MACE with a HR of 0.22 (95% CI: 0.07–0.68; p = .008) and thromboembolic events with a HR of 0.22 (95% CI: 0.06–0.75; p = .015). Triple antithrombotic therapy (TAT) with ticagrelor/prasugrel showed a strong and independent association with thrombus resolution with an adjusted HR of 3.25 (95% CI: 1.22–8.68; p = .019) compared to other strategies. Conclusion The presented data indicate a poor outcome of ACS patients experiencing LVT. In terms of a personalized risk stratification, thrombus resolution has a strong protective impact on both all‐cause death and MACE with the potential to tailor treatment decisions—including an intensified antithrombotic treatment approach—in this patient population.
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Affiliation(s)
- Felix Hofer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Niema Kazem
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Ronny Schweitzer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Patricia Horvat
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Max-Paul Winter
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Lorenz Koller
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Patrick Sulzgruber
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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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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Zhang Z, Si D, Zhang Q, Qu M, Yu M, Jiang Z, Li D, Yang P, Zhang W. Rivaroxaban versus Vitamin K Antagonists (warfarin) based on the triple therapy for left ventricular thrombus after ST-Elevation myocardial infarction. Heart Vessels 2021; 37:374-384. [PMID: 34420077 DOI: 10.1007/s00380-021-01921-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Left ventricular thrombus (LVT) can complicate ST-Elevation myocardial infarction (STEMI) and is associated with poor outcomes. Conventional triple anticoagulation [Vitamin K Antagonists (VKA) plus dual-antiplatelet therapy (DAPT)] is the first-line therapy for LVT after STEMI. In patients with LVT following STEMI, contemporary data of triple therapy with rivaroxaban are lacking. METHODS We conducted a retrospective cohort study involving 1335 STEMI patients who underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we observed differences in efficacy between rivaroxaban plus DAPT therapy and VKA plus DAPT. The time of LVT resolution was also evaluated, as well as net clinical adverse events, and rates of bleeding events. RESULTS In 1335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow-up period (median 25.0 months). Of the patients diagnosed with LVT, 31 patients were started on triple therapy with VKA, 33 patients on triple therapy with rivaroxaban. There was a consistent similarity in LVT resolution with rivaroxaban application compared to VKA application during the follow-up period [HR (log-rank test) 1.57(95% CI 0.89-2.77), p = 0.096; Adjusted HR 1.70(95% CI 0.90-3.22), p = 0.104]. Triple therapy with rivaroxaban showed quicker resolution than with VKA (6 months: p = 0.049; 12 months: p = 0.044; 18 months: p = 0.045). Similar risks of ISTH bleeding were not significantly different between the 2 groups [VKA 9.7% vs Rivaroxaban 6.1%, Adjusted HR 0.48 (95% CI 0.73-3.20); p = 0.444)]. Fewer net adverse clinical events (NACE) were observed in the rivaroxaban group [VKA 58.1% vs Rivaroxaban 24.2%; HR (log-rank test) 0.31(95% CI 0.14-0.68), p = 0.003; Adjusted HR 0.23(95% CI 0.09-0.57), p = 0.001]. CONCLUSION In the observational study, triple therapy with rivaroxaban has similar and quicker LVT resolution in patients with LVT after STEMI, compared with triple therapy with VKA, and perhaps was associated with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.
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Affiliation(s)
- Zhongfan Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Daoyuan Si
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Qian Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Ming Qu
- Department of Gastroenterology, Endoscopy Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Miao Yu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Zhenya Jiang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Delin Li
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Ping Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Wenqi Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China.
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Kitano T, Nabeshima Y, Kataoka M, Takeuchi M. Therapeutic efficacy of direct oral anticoagulants and vitamin K antagonists for left ventricular thrombus: Systematic review and meta-analysis. PLoS One 2021; 16:e0255280. [PMID: 34310654 PMCID: PMC8312978 DOI: 10.1371/journal.pone.0255280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/14/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Although several meta-analyses have compared efficacies of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) for treatment of left ventricular thrombus (LVT), those meta-analyses included no single-arm studies. METHODS AND RESULTS PubMed, Scopus, and the Cochrane Library databases were searched for articles investigating thrombus resolution, stroke, any thromboembolism, major bleeding, any bleeding, or all-cause death in LVT treated with VKAs or DOACs, and single-class meta-analyses were also included (PROSPERO database, CRD42021230849). Event rates were pooled using a random effects model. Meta-regression analysis was performed to explore factors that may influence outcomes. 2,612 patients from 23 articles were included (VKAs: 2,004, DOACs: 608). There were no significant differences between VKAs and DOACs in the frequency of thrombus resolution (VKAs: 0.75 [95% confidence interval; 0.67 to 0.81], DOACs: 0.75 [0.67 to 0.82]), stroke (VKAs: 0.06 [0.04 to 0.10], DOACs: 0.02 [0.01 to 0.01]), any thromboembolism (VKAs: 0.08 [0.05 to 0.13], DOACs: 0.03 [0.01 to 0.10]), major bleeding (VKAs: 0.06 [0.04 to 0.09], DOACs: 0.03 [0.01 to 0.06]), any bleeding (VKAs: 0.08 [0.05 to 0.12], DOACs: 0.08 [0.06 to 0.10]), and all-cause death (VKAs: 0.07 [0.04 to 0.13], DOACs: 0.09 [0.05 to 0.16]). Meta-regression analysis revealed that increased duration of follow-up was associated with lower-rates of stroke (estimate: -0.040, p = 0.0495) with VKAs, but not with DOACs. There was significant publication bias for thrombus resolution, stroke, any thromboembolism, any bleeding, and all-cause death. CONCLUSIONS Efficacy and adverse outcomes of therapy with DOACs and VKAs do not differ. Randomized controlled trials are needed to determine the optimal anticoagulant strategy.
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Affiliation(s)
- Tetsuji Kitano
- Department of Cardiology and Nephrology, Wakamatsu Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yosuke Nabeshima
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Masaharu Kataoka
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health Hospital, Kitakyushu, Japan
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Du C, Wang QM, Sun R, Wang LS. Treatment of left ventricular thrombus after myocardial infarction: need longer or lifetime use of anticoagulants? ESC Heart Fail 2021; 8:3437-3439. [PMID: 34033242 PMCID: PMC8318421 DOI: 10.1002/ehf2.13432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/25/2021] [Accepted: 05/04/2021] [Indexed: 01/14/2023] Open
Affiliation(s)
- Chong Du
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, 210029, China
| | - Qi-Ming Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, 210029, China
| | - Rui Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, 210029, China
| | - Lian-Sheng Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, 210029, China
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Rivaroxaban versus warfarin for the management of left ventricle thrombus. Egypt Heart J 2021; 73:41. [PMID: 33932172 PMCID: PMC8088413 DOI: 10.1186/s43044-021-00164-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/16/2021] [Indexed: 12/31/2022] Open
Abstract
Background Rivaroxaban has been recently introduced for the management of non-valvular intra-cardiac thrombosis with variable results. We aimed to compare the results of the off-label use of rivaroxaban versus warfarin in the management of patients with left ventricle (LV) thrombus. This research is a retrospective study conducted on 63 patients who had LV thrombus from January to December 2016. We compared patients treated with warfarin (n=35) to patients who had rivaroxaban (n=28), and study outcomes were time to thrombus resolution, bleeding, stroke, and mortality. Results The median duration of treatment was 9.5 (25th-75th percentiles: 6-32.5) months for rivaroxaban and 14 (3-41) months for warfarin. Thrombus resolution occurred in 24 patients in the warfarin group (68.6%) and 20 patients in the rivaroxaban group (71.4%). The median time to resolution in the warfarin group was 9 (4-20) months and 3 (2-11.5) months in the rivaroxaban group. Thrombus resolution was significantly faster in patients on rivaroxaban (p= 0.019). Predictors of thrombus resolution were thrombus surface area (HR: 1.21; CI 95% (1.0-1.46); p= .048) and the use of rivaroxaban (HR: 1.92; CI 95% (1.01-3.65); p= 0.048). There was no difference in stroke, bleeding, and mortality between both groups. Conclusion Rivaroxaban was as effective and safe as warfarin in managing patients with left ventricle thrombus. Larger randomized clinical trials are recommended to confirm our findings.
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Niazi AK, Kassem H, Shalaby G, Khaled S, Alzahrani MS, Ali HM, Aboulenein F. Incidence and Predictors of Left Ventricular (LV) Thrombus after ST-Elevation Myocardial Infarction (STEMI) in the Holy Capital of Saudi Arabia. J Saudi Heart Assoc 2021; 33:101-108. [PMID: 34183905 PMCID: PMC8143724 DOI: 10.37616/2212-5043.1243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/27/2021] [Accepted: 03/02/2021] [Indexed: 11/20/2022] Open
Abstract
Background Patients with acute myocardial infarction (AMI) especially those with large MI (myocardial infarction) as identified by ST elevation in multiple contiguous ECG leads or anterior MI, may suffer significant myocardial damage leading to impaired wall motion and contractility which may lead to the formation of left ventricular thrombus (LVT) in the patient. This study was aimed to establish the incidence of LV thrombus and determine the predictors associated with the formation of LV thrombus in patients with AMI. Methods This retrospective study was held at the only cardiothoracic centre of Makkah, which provides tertiary level cardiac services. A total of 3084 consecutive patients with acute MI between 2016 and 2019 were identified and divided into two groups i.e. group I (with LVT) and group II (without LVT). The case notes, echocardiography data and cardiac catheterization lab records were reviewed to identify patients with LV thrombus. Regression analysis was employed to evaluate the predictors responsible for the formation of LV thrombus. Results The overall incidence for LV thrombus was determined as 8.4% (n = 260/3084), while in the subpopulation of pilgrims, it was 8.2% (83/1001). Mean age for patients with and without LVT was 54 ± 11 years vs 56 ± 12 years (p < 0.003), respectively. There was no significant difference between the two groups with respect to gender, diabetes, hypertension, smoking, Arabic speaking or BMI>30. Coronary thrombus aspiration was utilized in 17% vs 12% (p < 0.023) patients with LVT and without LVT, respectively. It was observed that the patients with cardiac arrest tend to develop more LVT i.e. 8.5% vs 5.2% (p < 0.033). However, LV thrombus formation was significantly associated with anterior STEMI with incidence of LVT reaching 13.4% and low ejection fraction (all MI types) i-e. 32 ± 9% vs 42 ± 11%, with p < 0.000 for both independent predictors. Conclusions LV thrombus is a relatively common occurrence in patients with acute MI, especially those with anterior STEMI and low ejection fraction<30%. Appropriate imaging studies are required for all acute MI patients in order to ascertain the presence or absence of LV thrombus as it has major influence on further management.
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Affiliation(s)
- Azmat Khadija Niazi
- Cardiac Centre, King Abdullah Medical City (in Holy Capital), Makkah Al Mukarrama, Saudi Arabia
| | - Hoda Kassem
- Cardiac Centre, King Abdullah Medical City (in Holy Capital), Makkah Al Mukarrama, Saudi Arabia
| | - Ghada Shalaby
- Cardiac Centre, King Abdullah Medical City (in Holy Capital), Makkah Al Mukarrama, Saudi Arabia
| | - Sheeren Khaled
- Cardiac Centre, King Abdullah Medical City (in Holy Capital), Makkah Al Mukarrama, Saudi Arabia
| | | | - Hassan Mohammad Ali
- Cardiac Centre, King Abdullah Medical City (in Holy Capital), Makkah Al Mukarrama, Saudi Arabia
| | - Fatima Aboulenein
- Cardiac Centre, King Abdullah Medical City (in Holy Capital), Makkah Al Mukarrama, Saudi Arabia
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An Z, Gao Z, Wang L, Hou C, Zhang L, Gong S, Rao R, Li C, Qin Z. Prognostic Significance of B-Type Natriuretic Peptide in Patients With Left Ventricular Thrombus. Front Cardiovasc Med 2021; 8:667908. [PMID: 33996952 PMCID: PMC8116499 DOI: 10.3389/fcvm.2021.667908] [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: 02/15/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Aims: There is sparse information on the prognostic value of B-type natriuretic peptide (BNP) for the outcomes in patients with left ventricular thrombus (LVT). Methods: Patients diagnosed with LVT by transthoracic echocardiography between November 2009 to July 2020 at our institution were included. The endpoints were all-cause mortality and systemic embolism. Results: Ninety-two subjects were finally included in the study. The mean age of the cohort was 56.73 ± 14.12, and 80.4% of the patients were male. The median BNP (1st quartile−3rd quartile) was 437.5 (112.74–1317.5). The total all-cause mortality rate was 30.44% (28/92), and the 1-year, 2-year, and 3-year cumulative survival rates were 85.4, 75.5, and 66.5%, respectively. Systemic embolism was identified in 10 subjects. COX multivariate analysis showed that Log BNP (HR, 4.16; 95%CI, 1.81–9.56; P = 0.001) and BMI (HR, 0.86; 95%CI, 0.73–0.99; P = 0.048) were significantly associated with all-cause mortality. In addition, patients with BNP levels in the upper median (≥ 437.5 pg/ml) had significantly higher all-cause mortality rate compared to those with lower median BNP (<437.5 pg/ml; P = 0.004). The area under the receiver operating characteristic curve for BNP and all-cause mortality was 0.71. In the linear trend test, BNP quartiles were significantly related to all-cause mortality in all models, and the P-values for trend in models 1, 2, and 3 were 0.005, 0.006, and 0.048, respectively. Conclusion: BNP level is a prognostic factor for all-cause mortality in LVT patients, and elevated BNP is indicative of a higher risk of LVT.
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Affiliation(s)
- Zhixia An
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhichun Gao
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Luyu Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Changchun Hou
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Liying Zhang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Cardiology, Shapingba District People's Hospital, Chongqing, China
| | - Siming Gong
- Department of Ultrasound, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Rongsheng Rao
- Department of Ultrasound, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chun Li
- Department of Ultrasound, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhexue Qin
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Shah S, Shah K, Turagam MK, Sharma A, Natale A, Lakkireddy D, Garg J. Direct oral anticoagulants to treat left ventricular thrombus-A systematic review and meta-analysis: ELECTRAM investigators. J Cardiovasc Electrophysiol 2021; 32:1764-1771. [PMID: 33772939 DOI: 10.1111/jce.15016] [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] [Received: 12/06/2020] [Revised: 02/23/2021] [Accepted: 03/16/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Though current guidelines currently recommend using warfarin, there is also a growing interest in the utilization of direct oral anticoagulants (DOACs) to treat left ventricular (LV) thrombus. METHODS We performed a systematic search using PubMed, SCOPUS, EMBASE, Google Scholar, and ClinicalTrials.gov from inception to September 30, 2020, for studies that had reported outcomes in patients with left ventricular thrombus treated with DOACs (PROSPERO registration number CRD42020219761). RESULTS Twelve studies (n = 867 patients) were included in the analysis. The pooled incidence of the systemic embolic events (SEE) with DOACs was 2.7%, whereas the thrombus resolution rate was 86.6%. The pooled incidence of overall bleeding (composite of major and minor bleeding) and major bleeding with DOACs were 5.6% and 1.1%, respectively. No significant difference was observed in terms of SEE (OR 0.81, 95% confidence interval [CI] 0.44-1.52, p = .54), major bleeding (OR 0.29, 95% CI 0.07-1.26, p = .24), and failure of LV thrombus resolution (OR 0.86, 95% CI 0.28-2.58, p = .68); whereas overall bleeding was significantly low in patients with LV thrombus treated with DOACs compared to vitamin K antagonists (VKAs) (OR 0.33, 95% CI 0.14-0.81, p = .02). CONCLUSION Our study demonstrates no significant difference in SEE, major bleeding, or failure of LV thrombus resolution between the two groups, thus demonstrating that DOACs are an efficacious and safe alternative for the treatment of LV thrombus compared to VKAs. However, further well-designed prospective trials are needed to answer important clinical questions-optimal dosing/duration of DOACs and its safety in the background of antiplatelet therapy.
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Affiliation(s)
- Siddharth Shah
- Division of Cardiology, State University of New York Upstate Medical Center, Syracuse, New York
| | - Kuldeep Shah
- Department of Cardiovascular Medicine, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Mohit K Turagam
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Abhinav Sharma
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrea Natale
- Cardiac Arrhythmia Service, Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Dhanunjaya Lakkireddy
- Cardiac Arrhythmia Service, Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Kansas
| | - Jalaj Garg
- Division of Cardiology, Cardiac Arrhythmia Service, Medical College of Wisconsin, Milwaukee, Wisconsin
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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: 28] [Impact Index Per Article: 9.3] [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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Clinical characteristics and outcomes in patients with echocardiographic left ventricular spontaneous echo contrast. Int J Cardiol 2021; 330:245-250. [PMID: 33577908 DOI: 10.1016/j.ijcard.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/03/2021] [Accepted: 02/03/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spontaneous echo contrast (SEC) is a known precursor to thrombus formation and thromboembolic events. This study aims to demonstrate the clinical characteristics and outcomes of patients with left ventricular spontaneous echo contrast (LV-SEC). METHODS Patients with consecutive echocardiogram performed from October 2009 to September 2019 were enrolled in this retrospective, single-center study. Those with LV-SEC were included, while patients complicated by left ventricular thrombus, with history of infective endocarditis, prosthetic valves, or lost to follow-up were excluded. The clinical endpoint was 1-year thromboembolic events (i.e. stroke and peripheral embolism). RESULTS Among 417 patients (mean age 63.5 ± 14.7 years; 86.8% men) with LV-SEC, the incidence of 1-year embolism was 12.9%. In multivariate Cox proportional hazard model, significant risk factors for thromboembolic event were age [hazard ratio (HR) = 1.022, 95% confidence interval (CI): 1.000-1.045], atrial fibrillation (AF) (HR = 2.292, 95% CI: 1.237-4.244), hemoglobin (HR = 1.032, 95% CI: 1.017-1.047), left ventricular ejection fraction (LVEF) (HR = 1.021, 95% CI: 1.002-1.041), and anticoagulant therapy (HR = 0.310, 95% CI: 0.168-0.572). For patients with repeated measurements for echocardiography, D-dimer (HR = 1.137, 95% CI: 1.051-1.231), and △LVEF (HR = 0.961, 95% CI: 0.928-0.996) were independently associated with the persistent LV-SEC. CONCLUSION The present study reported a high incidence of 1-year thromboembolic event in patients with LV-SEC. Age, AF, hemoglobin, LVEF were independent risk factors for 1-year embolism and a reduced risk of embolism was observed among patients with anticoagulation therapy. Additionally, D-dimer and △LVEF are independently associated with the persistent LV-SEC.
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Kitahara S, Fujino M, Honda S, Asaumi Y, Kataoka Y, Otsuka F, Nakanishi M, Tahara Y, Ogata S, Onozuka D, Nishimura K, Fujita T, Tsujita K, Ogawa H, Noguchi T. COVID-19 pandemic is associated with mechanical complications in patients with ST-elevation myocardial infarction. Open Heart 2021; 8:e001497. [PMID: 33547221 PMCID: PMC7871043 DOI: 10.1136/openhrt-2020-001497] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/31/2020] [Accepted: 01/18/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Although there are regional reports that the COVID-19 pandemic is associated with a reduction in acute myocardial infarction presentations and primary percutaneous coronary intervention (PCI) procedures, little is known about the impact of the COVID-19 pandemic on mechanical complications resulting from ST-segment elevation myocardial infarction (STEMI) and mortality. METHODS This single-centre retrospective cohort study analysed presentations, incidence of mechanical complications, and mortality in patients with STEMI before and after a state of emergency was declared due to the COVID-19 pandemic by the Japanese government on 7 April 2020. RESULTS We analysed 359 patients with STEMI hospitalised before the declaration and 63 patients hospitalised after the declaration. The proportion of patients with late presentation was significantly higher after the declaration than before (25.4% vs 14.2%, p=0.03). The incidence of late presentation was significantly higher during the COVID-19 pandemic than before (incidence rate ratio (IRR), 2.41; 95% CI, 1.37 to 4.05; p=0.001, even after adjusting for month (IRR, 2.61; 95% CI, 1.33 to 5.13; p<0.01). Primary PCI was performed significantly less often after the declaration than before (68.3% vs 82.5%, p=0.009). The mechanical complication resulting from STEMI occurred in 13 of 359 (3.6%) patients before the declaration and 9 of 63 (14.3%) patients after the declaration (p<0.001). However, the incidence of in-hospital death (before, 6.2% vs after, 6.4%, p=0.95) was comparable. CONCLUSIONS Following the COVID-19 pandemic, an increased incidence of mechanical complications resulting from STEMI was observed. Instructing people to stay at home, without effectively educating them to immediately seek medical attention when suffering symptoms of a heart attack, may worsen outcomes in patients with STEMI.
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Affiliation(s)
- Satoshi Kitahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masashi Fujino
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Michio Nakanishi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Daisuke Onozuka
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Svendsen C, Pauley E, Falk K, Weickert T, Yeung M, Stouffer GA. Patients with Left Ventricular Thrombus Despite Normal Systolic Function. Am J Med Sci 2021; 362:198-206. [PMID: 34172202 DOI: 10.1016/j.amjms.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/19/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022]
Abstract
The formation of a thrombus in the left ventricle (LV) in patients with normal systolic function is very rare. We report a case and identified 31 other adult patients who had an LV thrombus with normal LV systolic function. The median (IQR) age of these patients was 43 [37,59] years with a slight male predominance (59%). The vast majority of patients presented with embolic complications (28; 88%) with 3 of the other patients presenting with a febrile illness. Most of the cases occurred in the setting of an identifiable medical condition that carries an increased risk of thrombosis including inflammatory diseases, malignancies or hypereosinophilia. Treatment generally included anticoagulation with or without surgical removal or systemic thrombolysis. Recurrence of LV thrombus and/or embolic events have been reported in patients with LV thrombus and normal LV systolic function suggesting that long term anticoagulation may be needed.
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Affiliation(s)
- Christopher Svendsen
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, NC, United States
| | - Eric Pauley
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - Kristine Falk
- The McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, United States
| | - Thelsa Weickert
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - Michael Yeung
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - George A Stouffer
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States; The McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, United States.
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