Review Article

Contemporary Review of the Management of Left Ventricular Thrombus

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Abstract

Although there is established evidence for the treatment of left ventricular thrombus (LVT) at the outset, the subsequent management of these patients is less well-defined. This review discusses the currently available evidence for the initial type and duration of anticoagulation for LVT and explores potential treatment options after the initial period of anticoagulation. Of 2,052 studies screened, 32 studies (with three randomised controlled trials) were included. The initial anticoagulation strategy was either warfarin or direct oral anticoagulants, with the majority of studies showing similar outcomes. If LVT persists, studies recommended continuing anticoagulation (n=11/17) or switching to a different class of anticoagulant (n=7/17). After resolution, five studies recommended continuing anticoagulation in the presence of high-risk features of recurrence (i.e. persistently depressed left ventricular ejection fraction and/or apical wall dyskinesia). Medical management should be optimised, together with the appropriate revascularisation strategy, as clinically indicated. Synthesising the evidence, a practical algorithm for the management of LVT is proposed.

Disclosure:JT received consulting fees from Elixir and Janssen, speaker’s honoraria from Medtronic, Amgen, Biotronik, Roche, Microport, MedAlliance, AstraZeneca, Boehringer Ingelheim and Terumo, is on the advisory board of Novartis, and holds the position of APSC immediate past president. JY received grants from the Singhealth Cardiovascular ACP Grant and speaker’s honoraria from Biosensors, Biotronik, Boston Scientific, Edwards Lifesciences, Johnson & Johnson, Kaneka, Medtronic and Terumo. LC, JT and JY are on the Journal of Asian Pacific Society of Cardiology editorial board; this did not influence peer review. All other authors have no conflicts of interest to declare.

Received:

Accepted:

Published online:

Correspondence Details:Jonathan Yap, National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609. E: jonathan.yap.j.l@singhealth.com.sg

Open Access:

This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

Left ventricular thrombus (LVT) is a well-known complication of acute MI (AMI) and non-ischaemic cardiomyopathies.1 The presence of LVT increases the risk of embolic complications, such as stroke or systemic embolisation, hence treatment with oral anticoagulation is often indicated.2 The European and American guidelines recommend a period of anticoagulation in patients with AMI and LVT.3,4 Currently, the oral anticoagulant (OAC) of choice is warfarin, a vitamin K antagonist (VKA). More recently, however, there has been increasing evidence to support the use of direct oral anticoagulants (DOACs), with several studies showing comparable efficacy and safety between them.5–13

Although the initial treatment options for LVT are better established, the management of patients after the initial duration of anticoagulation is more complex and varied. After a period of initial anticoagulation, subsequent repeat imaging is often done via transthoracic echocardiogram (TTE) with/without contrast and occasionally cardiac MRI (CMR) to assess for resolution of LVT.2 The rate of resolution of LVT following anticoagulation therapy varies widely, ranging from 48.1% to 91.7%, with a recurrence rate after anticoagulation of as high as 18.5%.5,7,14 Currently, in the AMI setting it is common practice to continue anticoagulation if the thrombus persists, and to potentially stop OAC and resume antiplatelet therapy if the thrombus resolves.15 However, patients with LVT often have a depressed LV ejection fraction (LVEF) and/or large akinetic/dyskinetic areas, particularly apical, which predispose to recurrent LVT formation, especially if these risk factors persist.16 Thus, the decision to continue or stop OACs in the absence of LVT following initial anticoagulation is not as straightforward.

This comprehensive literature review aims to synthesise the currently available evidence, provide recommendations for the initial pharmacological therapy for LVT and duration of treatment, and provide guidance on the subsequent treatment options after the initial period of anticoagulation.

Methods

A comprehensive search was performed of studies from inception until 1 July 2022 on the following electronic databases: MEDLINE (Ovid), Embase (Ovid), Scopus, and Google Scholar. The search consisted of the keywords ‘left ventricular thrombus’, ‘left ventricular clot’, ‘treatment’, ‘management’, and synonyms. The full search strategy can be found in Supplementary Material Appendix I. The retrieved papers were then exported into the systematic review managing software Covidence (Veritas Health Innovation), where duplicates were removed. The inclusion criterion was a report on the management of LVT. The exclusion criteria were a focus on paediatric populations, individual case reports, other reviews, and studies published in languages other than English. The titles and abstracts were initially screened, followed by an evaluation of the full text of the articles for relevance. The references of included studies were also subsequently screened to identify other potential studies. Data extracted from the papers consisted of publication details, patient characteristics, management options and outcomes.

Figure 1: PRISMA Flow Chart with Reasons for Exclusion

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Results

A total of 32 studies were included in the final analysis.13,16–46Figure 1 shows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. Twenty-three studies (71.9%) were retrospective cohort studies, three studies (9.4%) were case series, three studies (9.4%) were randomised controlled trials (RCTs), two studies (6.4%) were prospective cohort studies and one study (3.1%) was a non-randomised, open-label trial. An overall summary of all studies included is given in Supplementary Material Appendix II.

Aetiology

The most common underlying causes of LVT were AMI in 14 studies (43.8%), ischaemic cardiomyopathy in 13 studies (40.6%) and takotsubo cardiomyopathy in one study (3.1%). Four studies (12.5%) did not record aetiology.

Selected Studies Comparing Direct Oral Anticoagulants with Vitamin K Antagonists

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Cont.

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Initial Anticoagulation Strategy

The initial anticoagulation strategy included both DOACs and VKAs in 21 studies, VKA only in seven studies, DOACs only in three studies, and was not recorded in one study. Of these studies, two studies each also had patients on heparin and anti-platelets only as initial coagulation. Eighteen studies compared VKAs with DOACs (Table 1). For studies that used DOACs, 66.7% included more than one type of DOAC (from among apixaban, dabigatran, rivaroxaban or edoxaban), 15.6% used rivaroxaban only and 6.3% used apixaban only. Of the limited number of studies available for analysis, the majority showed similar outcomes between VKA and DOAC in terms of rates of LVT resolution, embolic events and bleeding events. One study showed superior LVT resolution with DOACs, and one study each showed fewer embolic events with warfarin and DOACs, respectively, two studies showed fewer bleeding events with DOACs, and one study showed fewer bleeding events with warfarin.17,27,30,39,40

Eight studies each (25.0%) described a median duration of OAC treatment of between 3 and 6 months, seven studies (21.9%) described a treatment duration of 6–12 months and seven studies (18.8%) described a median treatment duration of >12 months.16–19,21,23,24,28,30,32–
37,41,43,46
The median time to LVT resolution ranged from 2 to 3.4 months for DOACs and from 4 to 9 months for VKAs, with 70–86% of patients on DOACs and 49–76% of patients on VKAs achieving LVT resolution by 12 months.13,30,46 Five studies found a significantly shorter time to resolution with DOACs compared with VKAs. One study noted significantly fewer bleeding complications with the use of dual antithrombotic therapy (DAT) consisting of VKA with aspirin or clopidogrel, as compared with triple antithrombotic therapy (TAT), which consisted of VKA with aspirin and clopidogrel.24 In patients who require TAT due to persistent risk of thromboembolism, close follow-up is needed to identify any bleeding complications.46

Management after Initial Anticoagulation

Five studies repeated imaging less than 3 months after initial imaging, 10 studies repeated imaging between 3 and 6 months after initial imaging, and four studies repeated imaging more than 6 months after initial imaging.16–19,21,23,24,26,28–33,35,37,39–41 All studies used TTE with or without contrast as the imaging modality of choice, with select patients undergoing CMR.

Reported Management Strategies for Left Ventricular Thrombus Persistence on Follow-up

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Cont.

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Thrombus Persistence

Seventeen studies that reported on management strategies after follow-up echocardiography showed non-resolution of LVT (Table 2). Eleven of these studies (64.7%) reported that therapy continued.16,18,21,32,36–38,41,44–46 Six studies (37.5%) reported switching one anticoagulant class for another (i.e. DOAC for warfarin or vice versa) due to treatment failure.16,18,21,23,29,40 One study had a protocol whereby treatment failure with DOACs was switched to warfarin for 3 months with a higher target INR (international normalised ratio) of 3–4 as opposed to a target INR of 2–3 as recommended, and which achieved a 100% resolution rate in all patients who switched.23 One study used operative management (i.e. thrombectomy, Dor procedure) in patients with concomitant indications for surgery such as triple-vessel disease or severe aortic stenosis.33

Selected Studies Reporting on Management of Left Ventricular Thrombus Following Resolution

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Thrombus Resolution

Most studies (60%) reported withdrawal of OAC after thrombus resolution on repeat imaging. Seven studies proposed management strategies following LVT resolution (Table 3). Three studies suggested that continuing OAC should be considered in patients with impaired wall motion or large akinetic areas, or in patients with low LVEF or severe congestive heart failure.16,23,36–38 One study suggested stopping OAC earlier than at the proposed 6 months if repeat imaging at 3 months showed LVT resolution with recovery of apical wall motion.37

Discussion

Aetiology and Pathophysiology

In the majority (84%) of the studies included in this review, the most common aetiology of LVT was ischaemic heart disease. Other aetiologies recorded include dilated cardiomyopathy (DCM), hypertrophic obstructive cardiomyopathy and takotsubo cardiomyopathy.20,28,31–33,45 This could be significant, given that the different pathophysiologies of the differing aetiologies may influence the formation of LVT, which could have implications for therapy. For instance, endocardial injury and inflammation may be dominant factors in AMI, but stasis may be the dominant factor in DCM.47 Despite differing aetiologies, LVT due to ischaemic and non-ischaemic cardiomyopathies is treated similarly with anticoagulation.16,20,28,31,32,40 The 2022 American Heart Association (AHA) statement similarly recommends the use of OAC for 3 months in LVT due to AMI, and OAC for 3–6 months in patients with LVT due to DCM, and repeat imaging after initial duration of treatment.47

Initial Anticoagulation Strategy

The 2017 European Society of Cardiology guidelines recommended up to 6 months of anticoagulation if LVT is detected following AMI.3 The 2013 American College of Cardiology Foundation/AHA ST-elevation MI (STEMI) guidelines recommend as reasonable (class 2a, level c evidence) 3 months of VKA therapy for patients with STEMI and asymptomatic LVT with a target INR of 2–2.5 when combined with dual antiplatelet therapy (DAPT).4 The 2022 AHA scientific statement recommends treatment of post-MI LVT with an OAC for 3 months, for which DOACs are a reasonable alternative to warfarin.47

Comparison of the outcomes of initial anticoagulation options for LVT has been reported, with numerous observational studies and a limited number of small RCTs comparing DOACs with VKAs (Table 1). A large retrospective observational study by Robinson et al. involving 514 patients found that DOACs were associated with a significantly higher risk of stroke or systemic embolism.40 However, observational studies lend themselves to inherent bias and, therefore, cannot be used to formulate guidance on treatment strategies. Furthermore, to date, there are only three reported RCTs on the topic: the No-LVT trial, which randomised 79 patients to either rivaroxaban or warfarin; the study by Alcalai et al., which randomised 35 patients to apixaban or warfarin; and the study by Isa et al., which randomised 27 patients to apixaban or warfarin.17,19,43 These studies did not find a significant difference in terms of stroke, systemic embolism or major bleeding.17,19,43 Several meta-analyses have similarly found no significant difference in clinical outcomes.5–13 In addition, several observational studies have suggested that DOACs may be associated with a faster rate of resolution compared with warfarin.18,20,29,30,46 Thus, DOACs may be a reasonable alternative to warfarin, but larger RCTs are needed to validate this statement. There are two currently recruiting RCTs and two other observational studies that aim to further evaluate the efficacy and safety of DOACs versus warfarin in the treatment of LVT (Table 4). Before the results of these RCTs become available, we recommend warfarin as the standard of care due to its larger evidence base, with DOACs as a reasonable alternative, especially if there are issues with monitoring or maintaining therapeutic INR.

Upcoming Trials Evaluating Efficacy and Safety of Direct Oral Anticoagulants

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Concomitant Antiplatelet Therapy

Pertinent to this discussion is the issue of adjunctive antiplatelet therapy, on top of anticoagulation for LVT resolution. Most patients in the studies included were on concurrent antiplatelet therapy, with a significant number on DAPT, given that the majority of patients with LVT often have concurrent indications for antiplatelet therapy (e.g. MI, ischaemic heart disease). The decision to use a single or dual antiplatelet strategy depends on the patient’s bleeding risk, the strength of the indication for antiplatelet therapy, and the anticoagulant used.3 A retrospective study of 83 patients comparing the safety of DAT (consisting of warfarin with aspirin or clopidogrel), with that of TAT (warfarin with aspirin and clopidogrel), found a significantly increased risk of all-cause mortality, thromboembolic events, rehospitalisations for MI or heart failure and any bleeding at 1 year in the TAT group, with bleeding complications being the most significant.24 However, that study did not evaluate the efficacy of LVT resolution rates. Other trials that evaluated DAT versus TAT in patients with AF after percutaneous coronary intervention found DAT to be just as efficacious as TAT in terms of prevention of thromboembolic and major adverse cardiovascular events, with a significantly lower bleeding risk.48,49 Consequently, triple therapy for longer durations should be used only after careful consideration with close monitoring for bleeding complications. In patients with a strong indication for DAPT, several trials and observational studies have suggested that DOACs are a safer choice than warfarin.16,48–51 In patients requiring DAT or TAT, use of less potent antiplatelet agents such as aspirin or clopidogrel (versus ticagrelor) may be considered to reduce the bleeding risk.

Choice of Imaging Modality for LVT

Most studies repeated initial imaging within 3–6 months after initiation of anticoagulation, which corresponded closely to the median time to LVT resolution reported.18,29,32 All studies chose TTE (with/without contrast) as the imaging modality of choice. CMR may be considered if TTE is negative and there is a high clinical suspicion of persistent LVT, however, it is unclear whether treating LVT detectable only on CMR leads to improved outcomes.52 The 2022 AHA scientific statement recommends repeat imaging at 3 months with the same modality of imaging (or more detailed) that was used to initially diagnose the LVT.47 In the case of LVT persistence, thrombus morphology could be better assessed with contrast TTE, which improves the endocardial border definition, or CMR, which is considered the gold standard imaging technique in assessing the presence, size and location of LVT.53

Management Options for LVT Persistence

In large observational studies, the rate of thrombus resolution at 6 months ranged from more than 80% to as low as 30%.26,40 In the setting of persistent LVT, most studies continued anticoagulation or switched to a different anticoagulant (Table 2). In a retrospective study by Daher et al., LVT resolution rates were similar with both VKAs (INR target 2–3) and DOACs (71.5% versus 70.6%, p=0.9). Patients without LVT resolution on DOACs were switched to warfarin with a higher target INR of 3–4 for at least 3 months (n=5/17), and patients who switched all achieved LVT resolution.23 Other studies also recommended switching anticoagulation therapies when there was non-resolution of LVT, either from DOACs to VKAs or vice versa, or even switching to a different type of DOAC.16,29,43 On the basis of consensus opinion, the 2022 AHA statement recommended switching to an alternative OAC or low-molecular-weight heparin when initial therapy fails.47

Another factor to take note of is the morphology of LVT on TTE. Iqbal et al. reported that organised thrombus without high-risk features (non-mobile, non-protruding) was associated with a low rate of embolisation, allowing for possible safe withdrawal of anticoagulation despite persistent thrombus.28 The 2022 AHA statement stated that discontinuation of OAC in patients with persistent mural thrombus is not unreasonable, especially if the thrombus is calcified or organised.47

In the absence of other concomitant indications for surgery (e.g. coronary artery bypass, valve surgery etc.), there is insufficient available data to recommend surgical options solely for LVT management and this should be evaluated carefully on a case-by-case basis.47

Management Options after Thrombus Resolution

Most studies reported withdrawal of anticoagulation after LVT resolution. However, even with resolution of LVT, there is a persistent risk of thromboembolism.15 Some of these features can be evaluated on TTE and used to guide subsequent management. Observational studies found that impaired LV wall motion or large akinetic areas, or a significantly depressed LVEF were associated with a greater thromboembolic risk, even after LVT resolution.16,23,36–38 Blood stasis identified on CMR may also predict occurrence of embolic events after AMI and anticipate the recurrence of LVT after anticoagulation cessation.54,55 Prolonged antithrombotic therapy appears reasonable, especially if the LVEF or wall motion remains severely impaired.23,32,36 Alternatively, Daher et al. proposed that anticoagulation withdrawal earlier than 6 months can be considered if repeat imaging after 3 months shows resolution of thrombus with recovery of apical wall motion.23

Upon cessation of anticoagulation, the decision for antiplatelet therapy should be based on traditional clinical indications. Current reviews recommend the completion of 12 months of DAPT after cessation of anticoagulation therapy following AMI.15 In non-AMI patients, single antiplatelet therapy may be given in the presence of recommended conditions (i.e. coronary artery disease, stroke, peripheral vascular disease).28

Figure 2: Proposed Algorithm for the Management of LVT

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A Practical Approach to Managing LVT

Synthesising the available published evidence and literature, in Figure 2 we propose a simple, practical approach to the management of LVT. Patients with risk factors for LVT should be imaged initially with TTE with or without contrast, with consideration of CMR if clinical suspicion is high and TTE is negative.53 The choice of initial anticoagulation for most patients would be warfarin due to the larger evidence base, however, DOACs maybe a reasonable alternative given the growing literature supporting its use. In all cases it is important to continually optimise medical management and perform revascularisation, as clinically appropriate. TTE and/or CMR should be repeated at 3–6 months to assess for thrombus resolution.

In patients with persistence of thrombus, if they were initially on DOACs, switching to warfarin can be considered. For patients on warfarin, aiming for a higher target INR (e.g. increasing the target INR range from 2–3 to 2.5–3.5) can be considered. If the thrombus continues to persist on follow-up TTE, an assessment for the morphology of thrombus on TTE may be useful to guide further management. In patients who have high-risk features for embolisation (e.g. mobile or protruding thrombus), continuation of OAC should be considered, taking into account the bleeding risk. In patients with a mural, organised or calcified thrombus without high-risk features, withdrawal of OAC may be considered.

In patients with thrombus resolution, the LVEF and apical wall motion may facilitate decision-making with regard to the continuation of anticoagulation. In a patient with persistently depressed LVEF or large akinetic/aneurysmal areas of the LV, especially in the apex, continuation of OAC should be considered taking into account the bleeding risk. In patients with a significant improvement in LVEF and improved wall motion, OAC may be stopped and antiplatelet therapy continued as per clinical indications. In either case, upon cessation of anticoagulation, follow-up TTE should be performed to assess for thrombus recurrence.

Limitations

The conclusions derived from this review are subject to several limitations. Reflecting the current evidence base, the vast majority of studies included in this review were observational studies, which are inherently more prone to bias.56 Only three RCTs were available for inclusion, which were open-label in nature (owing to the use of warfarin and need for INR monitoring) and enrolled a relatively small number of participants, attributable to the difficulty in recruiting and randomising patients with LVT, which is not particularly common. The practical algorithm proposed was based on the synthesis of the available limited literature and expert opinion and will need to be taken in context in the management of the individual patient.

Conclusion

Current evidence on the management of LVT is limited. This updated review summarises the available evidence for the management for LVT and proposes a practical algorithm for the management of LVT. Future adequately powered RCTs with longer follow-ups are needed to further validate these recommendations.

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Clinical Perspective

  • With regards to the initial choice of anticoagulation for left ventricular thrombus (LVT), although warfarin has a larger evidence base, several studies have suggested that direct oral anticoagulants are just as effective and have a better safety profile.
  • In patients with persistent LVT, aiming for a higher target international normalised ratio or switching to a different class of anticoagulants may aid in clot resolution.
  • In patients with LVT resolution, certain high-risk features for recurrence, such as persistently depressed LV ejection fraction or apical wall akinesia, may prompt longer-term anticoagulation after discussion with the patient regarding the risks.

References

  1. Delewi R, Zijlstra F, Piek JJ. Left ventricular thrombus formation after acute myocardial infarction. Heart 2012;98:1743–9.
    Crossref | PubMed
  2. Cruz Rodriguez JB, Okajima K, Greenberg BH. Management of left ventricular thrombus: a narrative review. Ann Transl Med 2021;9:520.
    Crossref | PubMed
  3. Ibanez B, James S, Agewall S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119–77.
    Crossref | PubMed
  4. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78–140.
    Crossref | PubMed
  5. Chen Y, Zhu M, Wang K, et al. 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;79:935–40.
    Crossref | PubMed
  6. Abdelaziz HK, Megaly M, Debski M, et al. Meta-analysis comparing direct oral anticoagulants to vitamin K antagonists for the management of left ventricular thrombus. Expert Rev Cardiovasc Ther 2021;19:427-432.
    Crossref | PubMed
  7. Burmeister C, Beran A, Mhanna M, et al. Efficacy and safety of direct oral anticoagulants versus vitamin K antagonists in the treatment of left ventricular thrombus: a systematic review and meta-analysis. Am J Ther 2021;28:e411–9.
    Crossref | PubMed
  8. Li S, Deng Y, Tong Y, et al. Assessment of non-vitamin K antagonist oral anticoagulants for the management of left ventricular thrombus. Clin Cardiol 2021;44:754–60.
    Crossref | PubMed
  9. Camilli M, Lombardi M, Del Buono MG, et al. Direct oral anticoagulants vs. vitamin K antagonists for the treatment of left ventricular thrombosis: a systematic review of the literature and meta-analysis. Eur Heart J Cardiovasc Pharmacother 2021;7:e21–5.
    Crossref | PubMed
  10. Shah S, Shah K, Turagam MK, et al. Direct oral anticoagulants to treat left ventricular thrombus: a systematic review and meta-analysis: ELECTRAM investigators. J Cardiovasc Electrophysiol 2021;32:1764–71.
    Crossref | PubMed
  11. Saleiro C, Lopes J, De Campos D, et al. Left ventricular thrombus therapy with direct oral anticoagulants versus vitamin K antagonists: a systematic review and meta-analysis. J Cardiovasc Pharmacol Ther 2021;26:233–43.
    Crossref | PubMed
  12. Zhou K, Zhang X, Xiao Y, et al. Effectiveness and safety of direct-acting oral anticoagulants compared to vitamin K antagonists in patients with left ventricular thrombus: a meta-analysis. Thromb Res 2021;197:185–91.
    Crossref | PubMed
  13. Cochran JM, Jia X, Kaczmarek J, et al. Direct oral anticoagulants in the treatment of left ventricular thrombus: a retrospective, multicenter study and meta-analysis of existing data. J Cardiovasc Pharmacol Ther 2021;26:173–8.
    Crossref | PubMed
  14. Ebrahimi M, Fazlinezhad A, Alvandi-Azari M, Abdar Esfahani M. Long-term clinical outcomes of the left ventricular thrombus in patients with ST elevation anterior myocardial infarction. ARYA Atheroscler 2015;11:1–4
    PubMed
  15. Camaj A, Fuster V, Giustino G, et al. Left ventricular thrombus following acute myocardial infarction: JACC state-of-the-art review. J Am Coll Cardiol 2022;79:1010–22.
    Crossref | PubMed
  16. Varwani MH, Shah J, Ngunga M, Jeilan M. Treatment and outcomes in patients with left ventricular thrombus: experiences from the Aga Khan University Hospital, Nairobi – Kenya. Pan Afr Med J 2021;39:212.
    Crossref | PubMed
  17. Abdelnabi M, Saleh Y, Fareed A, et al. Comparative study of oral anticoagulation in left ventricular thrombi (no-LVT trial). J Am Coll Cardiol 2021;77:1590–2.
    Crossref | PubMed
  18. Albabtain MA, Alhebaishi Y, Al-Yafi O, et al. Rivaroxaban versus warfarin for the management of left ventricle thrombus. Egypt Heart J 2021;73:41.
    Crossref | PubMed
  19. Alcalai R, Butnaru A, Moravsky G, et al. Apixaban vs. warfarin in patients with left ventricular thrombus: a prospective multicenter randomized clinical trial. Eur Heart J Cardiovasc Pharmacother 2021;8:660–7.
    Crossref | PubMed
  20. Ali Z, Isom N, Dalia T, et al. Direct oral anticoagulant use in left ventricular thrombus. Thromb J 2020;18:29.
    Crossref | PubMed
  21. Bahmaid RA, Ammar S, Al-Subaie S, et al. Efficacy of direct oral anticoagulants on the resolution of left ventricular thrombus: a case series and literature review. JRSM Cardiovasc Dis 2019;8:2048004019839548.
    Crossref | PubMed
  22. Bass ME, Kiser TH, Page RL, 2nd, et al. Comparative effectiveness of direct oral anticoagulants and warfarin for the treatment of left ventricular thrombus. J Thromb Thrombolysis 2021;52:517–22.
    Crossref | PubMed
  23. Daher J, Da Costa A, Hilaire C, et al. Management of left ventricular thrombi with direct oral anticoagulants: retrospective comparative study with vitamin K antagonists. Clin Drug Investig 2020;40:343–53.
    Crossref | PubMed
  24. De Luca L, Putini RL, Natale E, et al. One-year clinical outcome of patients with left ventricular thrombus after acute myocardial infarction discharged on triple or dual antithrombotic therapy. J Thromb Thrombolysis 2022;53:410–6.
    Crossref | PubMed
  25. Fleddermann AM, Hayes CH, Magalski A, Main ML. Efficacy of direct acting oral anticoagulants in treatment of left ventricular thrombus. Am J Cardiol 2019;124:367–72.
    Crossref | PubMed
  26. Guddeti RR, Anwar M, Walters RW, et al. Treatment of left ventricular thrombus with direct oral anticoagulants: a retrospective observational study. Am J Med 2020;133:1488–91.
    Crossref | PubMed
  27. Herald J, Goitia J, Duan L, et al. Safety and effectiveness of direct oral anticoagulants versus warfarin for treating left ventricular thrombus. Am J Cardiovasc Drugs 2022;22:437–44.
    Crossref | PubMed
  28. Iqbal H, Straw S, Craven TP, et al. Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus. ESC Heart Fail 2020;7:2032–41.
    Crossref | PubMed
  29. Iskaros O, Marsh K, Papadopoulos J, et al. Evaluation of direct oral anticoagulants versus warfarin for intracardiac thromboses. J Cardiovasc Pharmacol 2021;77:621–31.
    Crossref | PubMed
  30. Jones DA, Wright P, Alizadeh MA, et al. The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction. Eur Heart J Cardiovasc Pharmacother 2021;7:398–404.
    Crossref | PubMed
  31. Kurisu S, Inoue I, Kawagoe T, et al. Incidence and treatment of left ventricular apical thrombosis in tako-tsubo cardiomyopathy. Int J Cardiol 2011;146:e58–60.
    Crossref | PubMed
  32. Lattuca B, Bouziri N, Kerneis M, et al. Antithrombotic therapy for patients with left ventricular mural thrombus. J Am Coll Cardiol 2020;75:1676–85.
    Crossref | PubMed
  33. Lee JM, Park JJ, Jung HW, et al. Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents. J Atheroscler Thromb 2013;20:73–93.
    Crossref | PubMed
  34. Lorente-Ros Á, Alonso-Salinas GL, Monteagudo Ruiz JM, et al. Effect of duration of anticoagulation in the incidence of stroke in patients with left-ventricular thrombus. Am J Cardiol 2022;185:115–21.
    Crossref | PubMed
  35. Makrides CA. Resolution of left ventricular postinfarction thrombi in patients undergoing percutaneous coronary intervention using rivaroxaban in addition to dual antiplatelet therapy. BMJ Case Rep 2016;2016:bcr-2016-217843.
    Crossref | PubMed
  36. Maniwa N, Fujino M, Nakai M, et al. Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction. Eur Heart J 2018;39:201–8.
    Crossref | PubMed
  37. Meurin P, Brandao Carreira V, Dumaine R, et al. Incidence, diagnostic methods, and evolution of left ventricular thrombus in patients with anterior myocardial infarction and low left ventricular ejection fraction: a prospective multicenter study. Am Heart J 2015;170:256–62.
    Crossref | PubMed
  38. Meurin P, Tabet JY, Renaud N, et al. Treatment of left ventricular thrombi with a low molecular weight heparin. Int J Cardiol 2005;98:319–23.
    Crossref | PubMed
  39. Mihm AE, Hicklin HE, Cunha AL, et al. Direct oral anticoagulants versus warfarin for the treatment of left ventricular thrombosis. Intern Emerg Med 2021;16:2313–7.
    Crossref | PubMed
  40. Robinson AA, Trankle CR, Eubanks G, et al. Off-label use of direct oral anticoagulants compared with warfarin for left ventricular thrombi. JAMA Cardiol 2020;5:685–92.
    Crossref | PubMed
  41. Shacham Y, Birati EY, Rogovski O, et al. Left ventricular thrombus formation and bleeding complications during continuous in-hospital anticoagulation for acute anterior myocardial infarction. Isr Med Assoc J 2012;14:742–6
    PubMed
  42. Sia CH, Leow AS-T, Tan BY, et al. Anticoagulation for the treatment of left ventricular thrombus in patients with acute myocardial infarction and renal impairment. Pol Arch Intern Med 2021;131:878–81.
    Crossref | PubMed
  43. Isa WYHW, Hwong N, Mohamed Yusof A, et al. Apixaban versus warfarin in patients with left ventricular thrombus: a pilot prospective randomized outcome blinded study investigating size reduction or resolution of left ventricular thrombus. Journal of Clinical and Preventive Cardiology. 2020;9:150–4.
    Crossref.
  44. Willeford A, Zhu W, Stevens C, Thomas IC. Direct oral anticoagulants versus warfarin in the treatment of left ventricular thrombus. Ann Pharmacother 2021;55:839–45.
    Crossref | PubMed
  45. Xu Z, Li X, Li X, et al. Direct oral anticoagulants versus vitamin K antagonists for patients with left ventricular thrombus. Ann Palliat Med 2021;10:9427–34.
    Crossref | PubMed
  46. Zhang Z, Si D, Zhang Q, et al. Rivaroxaban versus vitamin K antagonists (warfarin) based on the triple therapy for left ventricular thrombus after ST-elevation myocardial infarction. Heart Vessels 2022;37:374–84.
    Crossref | PubMed
  47. Levine GN, McEvoy JW, Fang JC, et al. Management of patients at risk for and with left ventricular thrombus: a scientific statement from the American Heart Association. Circulation 2022;146:e205–23.
    Crossref | PubMed
  48. Lopes RD, Heizer G, Aronson R, et al. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med 2019;380:1509–24.
    Crossref | PubMed
  49. Cannon CP, Bhatt DL, Oldgren J, et al. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med 2017;377:1513–24.
    Crossref | PubMed
  50. Gibson CM, Mehran R, Bode C, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med 2016;375:2423–34.
    Crossref | PubMed
  51. Sindet-Pedersen C, Lamberts M, Staerk L, et al. Combining oral anticoagulants with platelet inhibitors in patients with atrial fibrillation and coronary disease. J Am Coll Cardiol 2018;72:1790–800.
    Crossref | PubMed
  52. Velangi PS, Choo C, Chen KA, et al. Long-term embolic outcomes after detection of left ventricular thrombus by late gadolinium enhancement cardiovascular magnetic resonance imaging: a matched cohort study. Circ Cardiovasc Imaging 2019;12:e009723.
    Crossref | PubMed
  53. Weinsaft JW, Kim J, Medicherla CB, et al. Echocardiographic algorithm for post-myocardial infarction lv thrombus: a gatekeeper for thrombus evaluation by delayed enhancement CMR. JACC Cardiovasc Imaging 2016;9:505–15.
    Crossref | PubMed
  54. Massussi M, Cipriani A, Meneghin S, et al. Prognostic value of left ventricular blood stasis in patients with acute myocardial infarction: a cardiac magnetic resonance study. Int J Cardiol 2022;358:128–33.
    Crossref | PubMed
  55. Delgado-Montero A, Martinez-Legazpi P, Desco MM, et al. Blood stasis imaging predicts cerebral microembolism during acute myocardial infarction. J Am Soc Echocardiogr 2020;33:389–98.
    Crossref | PubMed
  56. Hess AS, Abd-Elsayed A. Observational studies: uses and limitations. In: Abd-Elsayed A, ed. Pain: A Review Guide. Berlin: Springer, Cham, 2019;123–5.
    Crossref