Emerging Trends in Left Ventricular Thrombus: A Comprehensive Review of Non-Ischemic and Ischemic Cardiopathies, Including Eosinophilic Myocarditis, Chagas Cardiomyopathy, Amyloidosis, and Innovative Anticoagulant Approaches

Abstract

This comprehensive review explores the intricate aspects of left ventricular thrombus (LVT), a potential complication in both ischemic and non-ischemic cardiomyopathies. It provides a thorough understanding of left ventricular thrombus, revealing its uncommon incidence in the general population (7 cases per 10,000 patients), predominantly linked to ischemic heart diseases (ICMs) at an 80% prevalence rate. Diagnostic tools, notably transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR), demonstrate varying sensitivity but remain indispensable in specific clinical contexts related to LVT as non-invasive diagnostic modalities. A detailed comparison between ICM patients and those with non-ischemic cardiomyopathy (NICM) who have left ventricular thrombus reveals subtle distinctions with significant clinical implications. This analysis underscores the importance of these imaging techniques in distinguishing between the two conditions. Additionally, we explored the occurrence of LVT in specific non-ischemic cardiomyopathies, including Takotsubo syndrome, hypertrophic cardiomyopathy, eosinophilic myocarditis, Chagas disease, cardiac amyloidosis, and several other conditions. The article further delves into anticoagulation strategies, thoroughly examining their impact on LVT regression and patient outcomes. Pharmacological interventions, with a focus on direct oral anticoagulants, emerge as promising alternatives; however, there is insufficient information on their efficiency and safety, especially in NICM population. In conclusion, this review highlights the complex nature of LVT, incorporating a range of etiopathogenic factors, diagnostic complexities, and evolving therapeutic approaches. It emphasizes the pressing need for ongoing research in this field.

Keywords: amyloidosis; anticoagulation; apical aneurysm; echocardiography; hypertrophic cardiomyopathy; ischemic heart disease; left ventricle dysfunction; left ventricle thrombus.

Figure 1

The background mechanism of left ventricle thrombus (LVT) formation in both ischemic and nonischemic cardiomyopathy is represented by the presence of left ventricle dysfunction in the context of multifactorial myocardial injury. Cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) evaluation constitutes the gold standard for LVT detection; however, the accessibility is limited. Therefore, echocardiography with or without contrast is routinely performed nowadays in the case of LVT suspicion. Currently, the medical management includes anticoagulation in addition to the specific treatment of the underlying cardiomyopathy.

Figure 2

Oncological therapies and cancer localizations associated with high incidence of thrombotic events. Intrinsic mechanisms triggering thrombosis vary from activation of pro-coagulant factors and process to inhibition of intrinsic anticoagulation action.