Use of direct oral anticoagulants in the treatment of left ventricular thrombi: A tertiary center experience and review of the literature

Shokr, Mohamed; Ahmed, Abdelrahman; Abubakar, Hossam; SayedAhmad, Ziad; Rashed, Ahmed; Afonso, Luís; Cardozo, Shaun

doi:10.1002/ccr3.1917

Cited by 24 publications

(26 citation statements)

References 37 publications

(57 reference statements)

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“…Previously, evidence for the use of DOACs in the setting of LVT have been confined to case reports and case series, and there remain limited comparative studies of DOACs versus VKA. 16 -29…”

Section: Introductionmentioning

confidence: 99%

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

Cochran

Jia

Kaczmarek

et al. 2020

J Cardiovasc Pharmacol Ther

109

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Aim: To compare the safety and efficacy of direct oral anticoagulants (DOAC) relative to vitamin K antagonists (VKA) for the treatment of left ventricular thrombus (LVT). Methods: This retrospective study enrolled patients diagnosed with LVT from 2014-2017. Patient characteristics and outcomes within 12 months of LVT diagnosis were recorded and analyzed. A meta-analysis was also performed by pooling our results with existing data in literature. Results: 14 DOAC and 59 VKA patients were included. Baseline demographic and clinical characteristics were similar except for age. Although more strokes within 12 months occurred in VKA (15%) than in DOAC (0%) patients, this was not statistically significant (p = 0.189). There were no significant differences in outcomes between patients on DOAC and VKA for acute coronary syndrome (ACS) (7%, vs 3.4%, p = .477), LVT resolution (86% vs 76%, p = .499) or bleeding (14% vs 14%, p = 1) within 12 months. The meta-analysis included 6 studies (n = 408 for DOACs; n = 1207 for VKA). There were no significant differences between DOACs versus VKAs with respect to odds for unresolved thrombus (OR 0.61, 95% CI 0.26,1.41), embolic events (OR 1.24, 95% CI 0.90,1.69), embolic events and death (OR 1.10, 95% CI 0.84,1.45) or bleeding events (OR 1.13, 95% CI 0.74,1.72). Conclusions: Our study and meta-analysis suggest similar efficacy and safety of DOACs in the treatment of LVT compared to VKA. These findings underscore the need for a randomized controlled trial.

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Section: Introductionmentioning

confidence: 99%

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

Cochran

Jia

Kaczmarek

et al. 2020

J Cardiovasc Pharmacol Ther

109

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“…The American College of Cardiology (ACC) has presented TTE as the screening modality of choice in patients presumed to have LVT, as performed in our patient. The pathophysiology of LVT formation is similar to other causes of thrombi formation, and can be explained by Virchow's triad: hypercoagulable state, stasis, and endothelial injury in addition to a low ejection fraction seen after a MI [8]. LV apical thrombi have also been associated with systemic thromboembolic events such as stroke leading to significant morbidity and mortality [5].…”

Section: Discussionmentioning

confidence: 95%

“…The management of LVT and associated embolization has been actively debated due to lack of randomized clinical control trials [8,10]. A cross-sectional study evaluating 35 patients with LV apical thrombi determined that the LVT resolved in all patients being treated with aspirin and warfarin.…”

Section: Discussionmentioning

confidence: 99%

Peripheral Embolization of Left Ventricular Thrombus Leading to Acute Bilateral Critical Limb Ischemia: A Rare Phenomenon

et al. 2020

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Left ventricular thrombus (LVT) is a well-known complication of myocardial infarction (MI) leading to significant morbidity and mortality. LVT can also lead to systemic thromboembolic events causing threatening limb ischemia. We report a rare case of critical bilateral limb ischemia that resulted from peripheral embolization of LVT post MI, which was managed successfully by emergent surgical intervention and anticoagulation. A 74-year-old male with a medical history of hypertension, diabetes, hyperlipidemia and coronary artery disease status post stenting of the left anterior descending and left circumflex arteries presented to the emergency department with typical chest pain and progressive shortness of breath. Cardiac troponin levels on admission were 35 ng/mL of blood. The patient subsequently underwent emergent cardiac catheterization which revealed significant triple vessel disease, and was referred for coronary artery bypass grafting (CABG) surgery. Transthoracic and transesophageal echocardiograms revealed the presence of an apical aneurysm with chronic organized mobile thrombus at the apex. Post CABG, the patient complained of excruciating right leg pain. Computed tomography (CT) angiogram of the abdominal aorta and lower extremities revealed a large embolus at the aortic bifurcation occluding the right and nearly occluding the left common iliac arteries and thrombus in the right popliteal artery. He underwent emergent vascular surgery with resolution of his symptoms and remained without further complications. The incidence of LVT remains high in post-MI patients, and complications of LVT are known to include thromboembolic events. Peripheral embolization of acute or chronic LVT leading to bilateral distal embolization and critical limb ischemia remains a rare occurrence. This case report aims to aid clinicians to recognize and promptly manage LVT and related arterial thromboembolic events with anticoagulation and emergent surgical intervention if limb ischemia develops.

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“…Our cases are supported by multiple published articles providing evidence on the efficacy of DOACs in the treatment of intracardiac thrombosis . Shokr et al 16 demonstrated multiple cases revealing the resolution of LV thrombus with apixaban and rivaroxaban. Several case reports have been published on LV thrombus secondary to tachycardia-induced and hypertrophic cardiomyopathies that have been treated with DOACs.…”

Section: Discussionmentioning

confidence: 99%

Novel oral anticoagulants in intracardiac thrombosis resolution: a case series

Al‐Sadawi

Francois

Ortega

et al. 2020

European Heart Journal - Case Reports

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Background Vitamin K antagonists (VKAs) have been regarded as the therapy of choice for intracardiac thrombosis for decades based mostly on observational data. The advent of direct oral anticoagulants (DOACs) has displaced VKAs as the first-line therapy for multiple thrombotic disorders but not for intracardiac thrombosis. Although limited, there is growing evidence that DOACs are effective for intracardiac thrombosis and some data suggest that thrombus resolution might be superior to that with warfarin. Case summary Here, we present a series of six patients with left atrial appendage thrombi were treated with a venous thromboembolic dose of DOACs with resolution within 2–6 months with no reported complications. Discussion This case series adds to the accumulating evidence supporting the efficacy of DOACs in the treatment of intracardiac thrombi.

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Use of direct oral anticoagulants in the treatment of left ventricular thrombi: A tertiary center experience and review of the literature

Cited by 24 publications

References 37 publications

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

Peripheral Embolization of Left Ventricular Thrombus Leading to Acute Bilateral Critical Limb Ischemia: A Rare Phenomenon

Novel oral anticoagulants in intracardiac thrombosis resolution: a case series

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