Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
ESC Heart Fail. 2023 Jun;10(3):1987-1995. doi: 10.1002/ehf2.14369. Epub 2023 Apr 3.
A left ventricular thrombus (LVT) is not uncommon in patients with impaired LV systolic function. However, the treatment strategy for LVT has not yet been fully established. We aimed to identify the factors influencing LVT resolution and the significance of LVT resolution on clinical outcomes.
We retrospectively investigated patients diagnosed with LVT with left ventricular ejection fraction (LVEF) < 50% on transthoracic echocardiography from January 2010 to July 2021 in a single tertiary centre. LVT resolution was monitored through serial follow-up transthoracic echocardiography. The primary clinical outcome was a composite of all-cause death, stroke, transient ischaemic attack, and arterial thromboembolic events. LVT recurrence was also evaluated in patients with LVT resolution.
There were 212 patients diagnosed with LVT (mean age, 60.5 ± 14.0 years; male, 82.5%). The mean LVEF was 33.1 ± 10.9%, and 71.7% of patients were diagnosed with ischaemic cardiomyopathy. Most patients were treated with vitamin K antagonists (86.7%), and 28 patients (13.2%) were treated with direct oral anticoagulants or low molecular weight heparin. LVT resolution was observed in 179 patients (84.4%). LVEF improvement failure within 6 months was a significant factor hindering LVT resolution (hazard ratio, HR: 0.52, 95% confidence interval, CI: 0.31-0.85, P = 0.010). During a median 4.0 years of follow-up (interquartile range, IQR: 1.9 to 7.3 years), 32 patients (15.1%) experienced primary outcomes (18 all-cause deaths, 15 strokes, and 3 arterial thromboembolisms) and 20 patients (11.2%) experienced LVT recurrence after LVT resolution. LVT resolution was independently associated with a lower risk for primary outcomes (HR: 0.45, 95% CI: 0.21-0.98, P = 0.045). In the patients with resolved LVT, discontinuation or duration of anticoagulation after resolution were not significant predictors for LVT recurrence, but LVEF improvement failure at LVT resolution was associated with a significantly higher risk of LVT recurrence (HR: 3.10, 95% CI: 1.23-7.78, P = 0.016).
This study suggests that LVT resolution is an important predictor for favourable clinical outcomes. LVEF improvement failure interfered with LVT resolution and appeared to be a crucial factor for LVT recurrence. After LVT resolution, continuation of anticoagulation did not seem to impact LVT recurrence and the prognosis.
左心室血栓（LVT）在左心室收缩功能受损的患者中并不少见。然而，LVT 的治疗策略尚未完全确立。我们旨在确定影响 LVT 消退的因素以及 LVT 消退对临床结局的意义。
我们回顾性调查了 2010 年 1 月至 2021 年 7 月在一家三级中心因左心室射血分数（LVEF）<50%经胸超声心动图诊断为 LVT 的患者。通过连续随访经胸超声心动图监测 LVT 消退情况。主要临床结局是全因死亡、卒中和短暂性脑缺血发作以及动脉血栓栓塞事件的复合终点。还评估了 LVT 消退患者的 LVT 复发情况。
共纳入 212 例 LVT 患者（平均年龄 60.5±14.0 岁；男性 82.5%）。平均 LVEF 为 33.1±10.9%，71.7%的患者被诊断为缺血性心肌病。大多数患者接受维生素 K 拮抗剂（86.7%）治疗，28 例（13.2%）患者接受直接口服抗凝剂或低分子肝素治疗。179 例（84.4%）患者 LVT 消退。6 个月内 LVEF 改善失败是影响 LVT 消退的显著因素（风险比，HR：0.52，95%置信区间，CI：0.31-0.85，P=0.010）。在中位 4.0 年的随访期间（四分位距，IQR：1.9 至 7.3 年），32 例患者（15.1%）发生主要结局（18 例全因死亡，15 例卒中和 3 例动脉血栓栓塞），20 例患者（11.2%）在 LVT 消退后发生 LVT 复发。LVT 消退与较低的主要结局风险独立相关（HR：0.45，95%CI：0.21-0.98，P=0.045）。在 LVT 消退的患者中，抗凝治疗的停药或持续时间并不是 LVT 复发的显著预测因素，但 LVT 消退时 LVEF 改善失败与 LVT 复发的风险显著增加相关（HR：3.10，95%CI：1.23-7.78，P=0.016）。
本研究表明，LVT 消退是临床结局良好的重要预测因素。LVEF 改善失败会干扰 LVT 消退，似乎是 LVT 复发的关键因素。LVT 消退后，继续抗凝似乎不会影响 LVT 复发和预后。
