Challenges in management of left ventricular thrombus

Abstract

Left ventricular thrombus (LVT) complicates both ischemic and non-ischemic cardiomyopathies and is a potential cause of thromboembolic complications such as stroke. Management of LVT in the 21st century is primarily based on studies before the widespread use of potent pharmacological and interventional therapies such as primary percutaneous coronary intervention, especially in the setting of acute myocardial infarction. Though advances in diagnostic technology have improved detection of LVT, clinicians face several uncertainties in the management of LVT in daily practice. The aim of this paper is to examine several controversies in the diagnosis and management of LVT. Prospective studies are needed to advance therapy of LVT.

Keywords: anterior myocardial infarction; left ventricular thrombus; thrombus.

Figure 1.

(a) Temporal trends in incidence of LV thrombus (LVT) in patients presenting with anterior myocardial infarction. (b) Cumulative incidence of LVT in studies reported in the pre-PCI era compared to PCI era (before and after 1995).

Figure 2.

Illustrative example of the use of echocardiography in the diagnosis of LVT. In this case, while the standard apical four-chamber view (a) was inconclusive, off-axis imaging provided a better appreciation of the size of thrombus (b). Appearance of the same thrombus using ultrasound contrast and live three-dimensional echocardiography (c and d). The protruding nature of the thrombus is better evident with these modalities.

Figure 3.

Illustrative example of the importance of late gadolinium enhancement (LGE) imaging in detection of left ventricular thrombus. The presence of apical thrombus (arrow) is clearly evident in LGE cardiac magnetic resonance (b) compared to cine-cardiac magnetic resonance (a).

Figure 4.

(a) Incidence of thromboembolism in left ventricular thrombus (LVT). (b) Cumulative incidence of thromboembolism with LVT in studies reported before and after 1995.

Figure 5.

Flowchart for guiding left ventricular thrombus management after myocardial infarction in the authors’ practice. The cells in orange are management decisions faced by clinicians for which no evidence exists.