Fate of left ventricular thrombi in patients with remote myocardial infarction or idiopathic cardiomyopathy

Left ventricular thrombosis caused cerebral embolism during venoarterial extracorporeal membrane oxygenation support: A case report

BACKGROUND

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO), an effective short-term circulatory support method for refractory cardiogenic shock, is widely applied. However, retrospective analyses have shown that VA-ECMO-assisted cases were associated with a relatively high mortality rate of approximately 60%. Embolization in important organs caused by complications of left ventricular thrombosis (LVT) during VA-ECMO is also an important reason. Although the incidence of LVT during VA-ECMO is not high, the consequences of embolization are disastrous.

CASE SUMMARY

A 37-year-old female patient was admitted to hospital because of fever for 4 d and palpitations for 3 d. After excluding the diagnosis of coronary heart disease, we established a diagnosis of "clinically explosive myocarditis". The patient still had unstable hemodynamics after drug treatment supported by VA-ECMO, with heparin for anticoagulation. On day 4 of ECMO support, a left ventricular thrombus attached to the papillary muscle root of the mitral valve was found by transthoracic echocardiography. Left ventricular decompression was performed and ECMO was successfully removed, but the patient eventually died of multiple cerebral embolism.

CONCLUSION

LVT with high mobility during VA-ECMO may cause embolism in important organs. Therefore, a "wait and see" strategy should be avoided.

Treatment and outcomes in patients with left ventricular thrombus - experiences from the Aga Khan University Hospital, Nairobi - Kenya

Introduction

left ventricular thrombus (LVT) may lead to thromboembolism and has been associated with increased morbidity and mortality. Little is known about the incidence, etiology and outcomes in patients with LVT in Africa. The objective was to determine the etiology, treatment practices, rate of resolution and clinical outcomes in patients with LVT in the region.

Methods

a review of all echocardiograms performed in 2017 and 2018 at the Aga Khan University Hospital, Nairobi was carried out and patients with LVT identified. Physician review of charts was performed to document clinical characteristics and outcomes.

Results

during the study period 100 patients with LVT were identified (1.3% of adult echoes). The mean LVEF was 28.5% (±11.0%) and 88 (88%) patients had an LVEF of less than 40%. Underlying etiology of LV dysfunction was post myocardial infarction (MI) in 28 (28%), chronic ischemic cardiomyopathy in 42(42%) and non-ischemic cardiomyopathy in 30 (30%) patients. In 15 (15%) patients a stroke or TIA predated the diagnosis of LVT. Long term anticoagulation was given to 92 (92%) patients. Among these, 34 (37%) received warfarin while 58 (63%) were treated with a DOAC. In the 64 patients who had reassessment imaging (median duration 177 days), complete thrombus resolution was noted in 38 (59.4%). One-year clinical outcome data was available for 85 patients: 13 (15.3%) patients had died, 4 (4.7%) had suffered a stroke, and 8(9.4%) had had a bleeding episode. Rates of thrombus resolution (warfarin 64%, DOAC 55.6%, p=0.51), stroke (warfarin 2.9%, DOAC 1.7%, p=1.0) and bleeding (warfarin 5.9%, DOAC 5.2%, p = 1.00 were not significantly different among patients treated with warfarin and DOAC.

Conclusion

we noted a high incidence of LVT compared to contemporary Western series. The majority of our patients were treated with DOACs. There were no significant differences in outcomes between patients treated with a DOAC and those receiving warfarin. Prospective evaluation on the efficacy and safety of DOACs for this indication is needed.

Predicting mortality, thrombus recurrence and persistence in patients with post-acute myocardial infarction left ventricular thrombus

Left ventricular thrombus (LVT) is a common complication of acute myocardial infarction and is associated with morbidity from embolic complications. Predicting which patients will develop death or persistent LVT despite anticoagulation may help clinicians identify high-risk patients. We developed a random forest (RF) model that predicts death or persistent LVT and evaluated its performance. This was a single-center retrospective cohort study in an academic tertiary center. We included 244 patients with LVT in our study. Patients who did not receive anticoagulation (n = 8) or had unknown (n = 31) outcomes were excluded. The primary outcome was a composite outcome of death, recurrent LVT and persistent LVT. We selected a total of 31 predictors collected at the point of LVT diagnosis based on clinical relevance. We compared conventional regularized logistic regression with the RF algorithm. There were 156 patients who had resolution of LVT and 88 patients who experienced the composite outcome. The RF model achieved better performance and had an AUROC of 0.700 (95% CI 0.553-0.863) on a validation dataset. The most important predictors for the composite outcome were receiving a revascularization procedure, lower visual ejection fraction (EF), higher creatinine, global wall motion abnormality, higher prothrombin time, higher body mass index, higher activated partial thromboplastin time, older age, lower lymphocyte count and higher neutrophil count. The RF model accurately identified patients with post-AMI LVT who developed the composite outcome. Further studies are needed to validate its use in clinical practice.

The Role of Antithrombotic Therapy in Heart Failure

Heart failure is a major contributor to global morbidity and mortality burden affecting approximately 1-2% of adults in developed countries, mounting to over 10% in individuals aged >70 years old. Heart failure is characterized by a prothrombotic state and increased rates of stroke and thromboembolism have been reported in heart failure patients compared with the general population. However, the impact of antithrombotic therapy on heart failure remains controversial. Administration of antiplatelet or anticoagulant therapy is the obvious (and well-established) choice in heart failure patients with cardiovascular comorbidity that necessitates their use, such as coronary artery disease or atrial fibrillation. In contrast, antithrombotic therapy has not demonstrated any clear benefit when administered for heart failure per se, i.e. with heart failure being the sole indication. Randomized studies have reported decreased stroke rates with warfarin use in patients with heart failure with reduced left ventricular ejection fraction, but at the expense of excessive bleeding. Non-vitamin K oral anticoagulants have shown a better safety profile in heart failure patients with atrial fibrillation compared with warfarin, however, current evidence about their role in heart failure with sinus rhythm is inconclusive and further research is needed. In the present review, we discuss the role of antithrombotic therapy in heart failure (beyond coronary artery disease), aiming to summarize evidence regarding the thrombotic risk and the role of antiplatelet and anticoagulant agents in patients with heart failure.

Shape and Mobility of a Left Ventricular Thrombus Are Predictors of Thrombus Resolution

BACKGROUND AND OBJECTIVES

Left ventricular (LV) apical thrombi are usually present with LV dilatation, and oral anticoagulants reduce embolic risk in these patients. However, echocardiographic data regarding thrombus resolution remain limited. We studied its echocardiographic features that were associated with early resolution (within 1 month).

METHODS

We performed a retrospective observational study by reviewing baseline and follow-up echocardiographic images and medical records in patients with LV apical thrombi.

RESULTS

Between January 2005 and December 2017, 77 patients (59 males, mean 61±12 years old) were enrolled. Patients were classified into 2 groups based on duration of thrombus resolution: group 1 showing resolution within 1 month (n=23) and group 2 with persistence after 1 month (n=54). Thrombus size was significantly smaller in group 1 (10.7±4.2 vs. 12.1±5.5 mm, p=0.046). Grade 1 mobility (partially mobile; odds ratio [OR], 7.800; p=0.012) and grade 2 mobility (highly mobile; OR, 14.625; p=0.002) were significantly associated with the early resolution. Round thrombi were associated with early resolution than mural form (OR, 3.187; p=0.026). Multivariate analysis showed that the mobility was the most important parameter, and a highly mobile (grade 2 mobility) LV apical thrombi showed earlier resolution (OR, 12.525; p=0.013). During the follow-up over 62±44 months, 25 patients (32.5%) had ≥1 adverse clinical events. The late resolution of thrombi was associated with poor long-term clinical outcomes (hazard ratio, 5.727; p=0.020).

CONCLUSIONS

Mobility of LV apical thrombi was the most important parameter associated with early thrombus resolution. Late resolution of LV apical thrombi was associated with poor long-term clinical outcomes.

A Large Left Ventricular Cystic Thrombus: Unusual Presentation of a Common Entity

•LV thrombi after AMI are a feared complication and are not uncommon. •LV thrombi can present unusually as cystic-like masses, warranting careful management. •Early identification and management of LV thrombi can prevent devastating sequelae.

Catheter Ablation of Ventricular Tachycardia in the Presence of an Old Endocavitary Thrombus Guided by Intracardiac Echocardiography

BACKGROUND

Catheter ablation of ventricular tachycardia (VT) in patients with structural heart disease (SHD) is effective in prevention of arrhythmia recurrences. However, endocardial ablation may be challenging in the presence of organized left ventricular (LV) endocavitary thrombus. Our goal was to analyze the results of VT ablation in patients with identified old thrombus.

METHODS AND RESULTS

We reviewed clinical and procedural data of 344 consecutive patients who underwent VT ablation for SHD. Old endocavitary thrombus was identified in four patients by preprocedural transthoracic echocardiography (TTE) and in four more patients by intracardiac echocardiography (ICE). All together, the case series of eight patients with detectable thrombus is reported. All patients (one woman, age: 67 ± 7 years) had postinfarction aneurysm (20 ± 8 years after the index myocardial infarction) and the thrombus was well organized without mobile structures. Arrhythmogenic substrate could not be obviously targeted beneath the base of thrombus; however, catheter ablation was successfully performed in the close vicinity. A total of 2.4 ± 1.2 procedures were necessary to abolish VT recurrences. Epicardial ablation was performed in three of eight (38%) patients as a second elective procedure. No procedural or periprocedural complications were observed. During the follow-up of 14 ± 15 months, two patients (25%) had sporadic VT recurrences.

CONCLUSIONS

ICE seems to be more sensitive for the detection of LV thrombi compared to TTE and is helpful in real-time navigation of mapping/ablation catheter. Besides potential thromboembolic risk, large thrombus may prevent accessibility to the "critical" portion of arrhythmia circuit and epicardial ablation is required in selected cases.

Anticoagulation in ischemic left ventricular aneurysm

OBJECTIVE

To evaluate the role of systemic anticoagulation using warfarin in patients with post-myocardial infarction left ventricular (LV) aneurysm formation with or without definite LV thrombus formation.

PATIENTS AND METHODS

This study included 648 patients with post-myocardial infarction LV aneurysm formation diagnosed retrospectively by 2-dimensional echocardiography from December 1, 1994, to February 29, 2012. Of these 648 patients, 106 patients received warfarin and 542 patients did not. We studied a composite of death, nonfatal myocardial infarction, cerebrovascular accident, and systemic embolization as the primary outcome and a composite of cerebrovascular accident and systemic embolization as the secondary outcome by using propensity score-adjusted multiple Cox proportional hazards regression analysis.

RESULTS

In patients with LV aneurysm, LV thrombus was observed in 89 patients (13.7%) and it was associated with a higher incidence of adverse secondary events (hazard ratio [HR], 3.63; 95% CI, 1.12-11.8; P=.03) in unadjusted analysis. However, in adjusted analysis, anticoagulation did not predict either a better or a worse outcome for primary outcomes (HR, 1.05; 95% CI, 0.67-1.64; P=.84) or for secondary outcomes (HR, 1.52; 95% CI, 0.670-3.46; P=.31). The benefit of anticoagulation was also not established in patients with LV thrombus (HR, 1.38; 95% CI, 0.32-5.97; P=.66).

CONCLUSION

In patients with ischemic LV aneurysms, oral anticoagulation therapy with warfarin may not be effective enough to reduce cardiac and cerebrovascular events including systemic embolism. Further studies are needed to confirm this finding.