The references of included studies were also subsequently screened to identify other potential studies. The titles and abstracts were initially screened, followed by an evaluation of the full text of the articles for relevance. The exclusion criteria were a focus on paediatric populations, individual case reports, other reviews, and studies published in languages other than English. The inclusion criterion was a report on the management of LVT. The retrieved papers were then exported into the systematic review managing software Covidence (Veritas Health Innovation), where duplicates were removed. The full search strategy can be found in Supplementary Material Appendix I. The search consisted of the keywords ‘left ventricular thrombus’, ‘left ventricular clot’, ‘treatment’, ‘management’, and synonyms. 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.Ī 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. 16 Thus, the decision to continue or stop OACs in the absence of LVT following initial anticoagulation is not as straightforward. 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. 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. 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%. 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. 5–13Īlthough the initial treatment options for LVT are better established, the management of patients after the initial duration of anticoagulation is more complex and varied. 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. 3, 4 Currently, the oral anticoagulant (OAC) of choice is warfarin, a vitamin K antagonist (VKA). 2 The European and American guidelines recommend a period of anticoagulation in patients with AMI and LVT. 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. Left ventricular thrombus (LVT) is a well-known complication of acute MI (AMI) and non-ischaemic cardiomyopathies. Synthesising the evidence, a practical algorithm for the management of LVT is proposed. Medical management should be optimised, together with the appropriate revascularisation strategy, as clinically indicated. persistently depressed left ventricular ejection fraction and/or apical wall dyskinesia). After resolution, five studies recommended continuing anticoagulation in the presence of high-risk features of recurrence (i.e. If LVT persists, studies recommended continuing anticoagulation (n=11/17) or switching to a different class of anticoagulant (n=7/17). The initial anticoagulation strategy was either warfarin or direct oral anticoagulants, with the majority of studies showing similar outcomes. Of 2,052 studies screened, 32 studies (with three randomised controlled trials) were included. 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. 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.
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