From the Guidelines
Left ventricular thrombus can lead to serious complications, primarily systemic embolization with stroke being the most devastating outcome, as identified in the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. The initial manifestation of LV thrombus is often stroke, highlighting the need for early identification and prevention of LV thrombus formation to prevent stroke. Advanced imaging methods, such as strain patterns, blood vector mapping, and hematologic assays, offer the promise of identifying features of ventricular remodeling or dysfunction that point to patients who are at highest risk and would benefit from prophylactic anticoagulation 1. Some of the complications of LV thrombus include:
- Systemic embolization, with stroke being the most common and devastating outcome
- Peripheral arterial embolism affecting limbs, kidneys, or mesenteric circulation, which can cause ischemia or infarction in these territories
- The risk of embolization is highest in the first few months after thrombus formation, particularly with mobile or protruding thrombi
- Underlying cardiac conditions like myocardial infarction or dilated cardiomyopathy should be optimally managed to improve left ventricular function and prevent thrombus recurrence The optimal duration of anticoagulation in the setting of thrombus remains elusive, and natural history studies with serial advanced imaging could better determine LV thrombus embolic risk and the need for anticoagulation 1. Warfarin together with aspirin is the standard antithrombotic regimen to minimize the risk of LVAD pump thrombosis and to prevent recurrent ischemic stroke or TIA, although the use of DOACs in patients with LVAD should be avoided 1. Patients with left ventricular thrombus require close monitoring with serial echocardiography every 1-3 months to assess for thrombus resolution. Anticoagulation carries bleeding risks that must be balanced against the embolic risk, with regular monitoring of bleeding parameters recommended during treatment.
From the Research
Complications of Left Ventricular Thrombus
- Systemic thromboembolism is a known complication of left ventricular thrombus, as stated in 2 and 3
- Embolic events, including stroke, can occur even after resolution of the thrombus, as mentioned in 4
- Increased risk of cardiovascular events and death is associated with left ventricular thrombus, as indicated in 4
Risk Factors for Complications
- Anterior myocardial infarction, involvement of left ventricular apex, and reduced left ventricular ejection fraction are predictors of left ventricular thrombus, as stated in 4
- Large infarct size, severe diastolic dysfunction, and LV akinesis or dyskinesis are also risk factors for left ventricular thrombus, as mentioned in 4
Treatment and Management
- Anticoagulant therapy for at least 3 months can reduce the risk of systemic embolism, stroke, and cardiovascular events, as stated in 4
- Direct oral anticoagulants (DOACs) are being increasingly used for the management of left ventricular thrombus, despite lack of randomized trials, as mentioned in 5 and 6
- The use of DOACs has shown promise in reducing the risk of embolic events and demonstrating rapid reduction in size or full resolution of the thrombus, as stated in 3 and 6