Skip to main content
SpringerLink
Log in

Management of Left Ventricular Thrombi with Direct Oral Anticoagulants: Retrospective Comparative Study with Vitamin K Antagonists

  • Original Research Article
  • Published:
Clinical Drug Investigation Aims and scope Submit manuscript

Abstract

Background and Objectives

The efficacy of direct oral anticoagulants (DOACs) in the management of left ventricular (LV) thrombi remains to be determined, especially in patients with ischemic cardiomyopathy. This retrospective study sought to compare the efficacy of vitamin K antagonists (VKAs) and DOACs in patients with LV thrombi and evaluate the rate of LV thrombus resolution after adjusting anticoagulation.

Methods

This observational retrospective study included patients admitted to our institution for LV thrombus between January 2010 and August 2019. The rate of LV thrombus resolution was compared between VKAs and DOACs. Patients without thrombus resolution with DOAC treatment were switched to VKA agents in order to obtain an international normalized ratio (INR) of 3–4.

Results

Between January 2010 and August 2019, 59 consecutive patients with LV thrombi detected by transthoracic echocardiography were included in the study. The mean age was 62 ± 14 years and 16.9% were women. The circumstances of LV thrombus discovery were as follows: acute myocardial infarction or ischemic myocardiopathy (n = 22), stroke (n = 6), chest pain (n = 7), heart failure (n = 11), transthoracic echocardiographic evaluation (n = 11), and ventricular arrhythmias (n = 2). The proportion of patients on DOACs was 28.8% (n = 17), while that of those on VKAs was 71.2% (n = 42). Thrombus resolution was obtained in 70.6% (12/17) of patients on DOACs and in 71.4% (30/42) of those on VKAs (p = 0.9). Patients who failed to respond to DOAC treatment were treated with VKAs, and following this treatment adjustment all LV thrombi were dissolved in the DOAC group (5/5). Five embolic events (8.4% of stroke) occurred before the treatment initiation and six with anticoagulants (2/17 with DOACs [11.8%] and 4/42 with VKAs [9.5%]; p = 0.8).

Conclusions

This retrospective observational study found a similar efficacy between DOAC and VKA agents in patients with LV thrombi (70.6% vs. 71.5%); however, when the thrombus remains, VKAs are still the standard of care as it is possible to control INR levels (3–4) with them.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Solheim S, Seljeflot I, Lunde K, et al. Frequency of left ventricular thrombus in patients with anterior wall acute myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy. Am J Cardiol. 2010;106:1197–200.

    Article  PubMed  Google Scholar 

  2. Mao TF, Bajwa A, Muskula P, et al. Incidence of left ventricular thrombus in patients with acute ST-segment elevation myocardial infarction treated with percutaneous coronary intervention. Am J Cardiol. 2018;121(1):27–31.

    Article  PubMed  Google Scholar 

  3. Kupper AJ, Verheugt FW, Peels CH, Galema TW, Roos JP. Left ventricular thrombus incidence and behavior studied by serial two-dimensional echocardiography in acute anterior myocardial infarction: left ventricular wall motion, systemic embolism and oral anticoagulation. J Am Coll Cardiol. 1989;13:1514–20.

    Article  CAS  PubMed  Google Scholar 

  4. Gianstefani S, Douiri A, Delithanasis I, et al. Incidence and predictors of early left ventricular thrombus after ST-elevation myocardial infarction in the contemporary era of primary percutaneous coronary intervention. Am J Cardiol. 2014;113(7):1111–6.

    Article  PubMed  Google Scholar 

  5. Robinson AA, Jain A, Gentry M, McNamara RL. Left ventricular thrombi after STEMI in the primary PCI era: a systematic review and meta-analysis. Int J Cardiol. 2016;221:554–9.

    Article  PubMed  Google Scholar 

  6. Maniwa N, Fujino M, Nakai M, et al. Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction. Eur Heart J. 2018;39(3):201–8.

    Article  CAS  PubMed  Google Scholar 

  7. Vaitkus PT, Barnathan ES. Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: a meta-analysis. J Am Coll Cardiol. 1993;22(4):1004–9.

    Article  CAS  PubMed  Google Scholar 

  8. Steg PG, James SK, Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC), et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569–619.

    Article  CAS  PubMed  Google Scholar 

  9. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39:119–77.

    Article  PubMed  Google Scholar 

  10. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th edn: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):7S–47S.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Heidbuchel H, Verhamme P, Alings M, et al. European Heart Rhythm Association practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013;15(5):625–51.

    Article  PubMed  Google Scholar 

  12. Aydin F, Turgay Yildirim O, Huseyinoglu Aydin A, Dagtekin E, Aksit E. Is rivaroxaban a safe choice for apical thrombus in atrial fibrillation patients? A case report. J Stroke Cerebrovasc Dis. 2018;27(9):e203–5.

    Article  PubMed  Google Scholar 

  13. Noflatscher M, Moes N, Gassner EM, Marschang P. Dabigatran added to dual antiplatelet therapy to treat a left ventricular thrombus in an 87 year old patient with myocardial infarction and very high bleeding risk. Front Pharmacol. 2018;4(9):217.

    Article  Google Scholar 

  14. Elikowski W, Małek-Elikowska M, Fertała N, Zawodna M, Kruzel K. Fast apixaban-related resolution of left ventricular thrombi in a patient with dilated cardiomyopathy. Pol Merkur Lekarski. 2018;44(259):19–22.

    PubMed  Google Scholar 

  15. Sun H, Zhao Q, Wang Y, et al. Daily 10  mg rivaroxaban as a therapy for ventricular thrombus related to left ventricular non-compaction cardiomyopathy: a case report. Medicine (Baltimore). 2018;97(4):e9670.

    Article  Google Scholar 

  16. Adar A, Onalan O, Cakan F. Newly developed left ventricular apical thrombus under dabigatran treatment. Blood Coagul Fibrinol. 2018;29(1):126–8.

    Article  Google Scholar 

  17. Smetana KS, Dunne J, Parrott K, et al. Oral factor Xa inhibitors for the treatment of left ventricular thrombus: a case series. J Thromb Thromb. 2017;44(4):519–24.

    Article  Google Scholar 

  18. Seecheran R, Seecheran V, Persad S, Seecheran NA. Rivaroxaban as an antithrombotic agent in a patient with ST-segment elevation myocardial and left ventricular thrombus: a case report. J Investig Med High Impact Case Rep. 2017;5(1):2324709617697991.

    PubMed  PubMed Central  Google Scholar 

  19. Elikowski W, Małek-Elikowska M, Słomczyński M, Ganowicz-Kaatz T, Bolewski A, Skrzywanek P. Rivaroxaban-resistant right ventricular thrombus, successfully treated with vitamin K antagonist in a patient with dilated cardiomyopathy. Pol Merkur Lekarski. 2016;41(245):238–42.

    PubMed  Google Scholar 

  20. Makrides CA. Resolution of left ventricular postinfarction thrombi in patients undergoing percutaneous coronary intervention using rivaroxaban in addition to dual antiplatelet therapy. BMJ Case Rep. 2016;2016:bcr2016217843.

  21. Kaya A, Hayıroğlu Mİ, Keskin M, Tekkeşin Aİ, Alper AT. Resolution of left ventricular thrombus with apixaban in a patient with hypertrophic cardiomyopathy. Turk Kardiyol Dern Ars. 2016;44(4):335–7.

    PubMed  Google Scholar 

  22. Kolekar S, Munjewar C, Sharma S. Dabigatran for left ventricular thrombus. Indian Heart J. 2015;67(5):495–6.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Ohashi N, Okada T, Uchida M, Amioka M, Fujiwara M, Kaseda S. effects of dabigatran on the resolution of left ventricular thrombus after acute myocardial infarction. Intern Med. 2015;54(14):1761–3.

    Article  PubMed  Google Scholar 

  24. Mano Y, Koide K, Sukegawa H, Kodaira M, Ohki T. Successful resolution of a left ventricular thrombus with apixaban treatment following acute myocardial infarction. Heart Vessels. 2016;31(1):118–23.

    Article  PubMed  Google Scholar 

  25. Padilla Pérez M, Salas Bravo D, Garcelán Trigo JA, et al. Resolution of left ventricular thrombus by rivaroxaban. Future Cardiol. 2014;10(3):333–6.

    Article  CAS  PubMed  Google Scholar 

  26. Nagamoto Y, Shiomi T, Matsuura T, et al. Resolution of a left ventricular thrombus by the thrombolytic action of dabigatran. Heart Vessels. 2014;29(4):560–2.

    Article  PubMed  Google Scholar 

  27. Kaku B. Intra-cardiac thrombus resolution after anti-coagulation therapy with dabigatran in a patient with mid-ventricular obstructive hypertrophic cardiomyopathy: a case report. J Med Case Rep. 2013;7:238.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Chung K, Paek YM, Lee HJ, Hong K-S. Dabigatran effect on left ventricular thrombus in a patient with acute ischemic stroke. J Stroke. 2015;17(3):366–8.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Nakasuka K, Ito S, Noda T, et al. Resolution of left ventricular thrombus secondary to tachycardia-induced heart failure with rivaroxaban. Case Rep Med. 2014;2014:814524.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Cross P, Stewart R. Left ventricular mural thrombus treated with dabigatran. J Case Rep Stud. 2014;2(4):402.

    Google Scholar 

  31. Berry A, Brancheau D, Zughaib M. Rapid resolution of left ventricular thrombus with apixaban therapy. SAGE Open Med Case Rep. 2017;5:2050313X17745211.

  32. Abubakar H, Yassin AS, Shokr M. Rivaroxaban used for treatment of a left ventricular thrombus in a patient with nonischemic cardiomyopathy. Am J Ther. 2018;25(6):e706–9.

    Article  PubMed  Google Scholar 

  33. Da Costa A, Delolme C, Guichard JB, et al. Comparison of prevalence and management of left atrial appendage thrombi under old and new anticoagulants prior to left atrial catheter ablation. Am Heart J. 2017;193:8–15.

    Article  PubMed  Google Scholar 

  34. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1–39.

    Article  PubMed  Google Scholar 

  35. Weinsaft JW, Kim HW, Crowley AL, et al. LV thrombus detection by routine echocardiography: insights into performance characteristics using delayed enhancement CMR. JACC Cardiovasc Imaging. 2011;4(7):702–12.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Pöss J, Desch S, Eitel C, de Waha S, Thiele H, Eitel I. Left ventricular thrombus formation after ST-segment-elevation myocardial infarction: insights from a cardiac magnetic resonance multicenter study. Circ Cardiovasc Imaging. 2015;8(10):e003417.

    Article  PubMed  Google Scholar 

  37. Phan J, Nguyen T, French J, et al. Incidence and predictors of left ventricular thrombus formation following acute ST-segment elevation myocardial infarction: a serial cardiac MRI study. Int J Cardiol Heart Vasc. 2019;24:100395.

    PubMed  PubMed Central  Google Scholar 

  38. Merkler AE, Alakbarli J, Gialdini G, et al. Short-term risk of ischemic stroke after detection of left ventricular thrombus on cardiac magnetic resonance imaging. J Stroke Cerebrovasc Dis. 2019;28(4):1027–31.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2014;45(7):2160–236.

    Article  PubMed  Google Scholar 

  40. Dewilde WJM, Oirbans T, Verheugt FWA, WOEST Study Investigators, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013;381(9872):1107–15.

    Article  CAS  PubMed  Google Scholar 

  41. Bulluck H, Chan MHH, Paradies V, et al. Incidence and predictors of left ventricular thrombus by cardiovascular magnetic resonance in acute ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: a meta-analysis. J Cardiovasc Magn Reson. 2018;20(1):72.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Fleddermann AM, Hayes CH, Magalski A, Main ML. Efficacy of direct acting oral anticoagulants in treatment of left ventricular thrombus. Am J Cardiol. 2019;124(3):367–72.

    Article  CAS  PubMed  Google Scholar 

  43. Bahmaid RA, Ammar S, Al-Subaie S, Soofi MA, Mhish H, Yahia MA. Efficacy of direct oral anticoagulants on the resolution of left ventricular thrombus-a case series and literature review. JRSM Cardiovasc Dis. 2019;8:2048004019839548.

    PubMed  PubMed Central  Google Scholar 

  44. Yildirim E, Kalkan K, Ipek E, Demirelli S, Ermiş E. Successful resolution of left ventricular thrombus with apixaban treatment. Int J Cardiovasc Acad. 2016;2:57–8.

    Article  Google Scholar 

  45. Azizi A, Puricel S, Cook S, Brugger N. Rivaroxaban dissolves postinfarction left ventricular thrombus. Cardiovasc Med. 2016;19:25–7.

    Article  Google Scholar 

  46. Shokr M, Ahmed A, Abubakar H, et al. Use of direct oral anticoagulants in the treatment of left ventricular thrombi: a tertiary center experience and review of the literature. Clin Case Rep. 2019;7(1):135–42.

    Article  PubMed  Google Scholar 

  47. Cheong K-I, Chuang W-P, Wu Y-W, Huang S-H. Successful resolution of left ventricular thrombus after ST-elevation myocardial infarction by edoxaban in a patient with high bleeding risk. Acta Cardiol Sin. 2019;35(1):85–8.

    PubMed  PubMed Central  Google Scholar 

  48. Abdelnaby M, Almaghraby A, Abdelkarim O, Saleh Y, Hammad B, Badran H. The role of rivaroxaban in left ventricular thrombi. Anatol J Cardiol. 2019;21(1):47–50.

    PubMed  PubMed Central  Google Scholar 

  49. Yamamoto T, Konishi T, Funayama N, Kikuchi B, Hotta D, Ohori K. Resolution of left ventricular thrombus after dabigatran therapy in two patients with old anteroseptal myocardial infarction. Cardiol Pharmacol. 2015;4:152.

    Article  Google Scholar 

  50. Elikowski W, Małek-Elikowska M, Wróblewski D, et al. Apixaban in left ventricular thrombi treatment—a report of seven cases. Pol Merkur Lekarski. 2018;44(264):276–9.

    PubMed  Google Scholar 

  51. Kao P-H, Chou P-Y, Hsu P-C, Huang T-C. Resolution of left ventricular thrombus by edoxaban after failed treatment with warfarin overdose: a case report. Medicine (Baltimore). 2019;98(2):e14065.

    Article  Google Scholar 

  52. Huang L-Y, Chang T-H, Wu C-H, Tsai T-N. Warfarin-resistant left ventricular thrombus completely dissolved by rivaroxaban. Br J Hosp Med (Lond). 2018;79(11):648–9.

    Article  Google Scholar 

  53. Bennett S, Satchithananda D, Law G. The use of apixaban for the treatment of an LV thrombus. Echo Res Pract. 2018;5(4):K63–6.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Nafee T, Aslam A, Chi G, et al. Andexanet alfa for the reversal of anticoagulant activity in patients treated with direct and indirect factor Xa inhibitors. Expert Rev Cardiovasc Ther. 2017;15(4):237–45.

    Article  CAS  PubMed  Google Scholar 

  55. Lip G, Hammerstingl C, Marin F, X-TRA Study and CLOT-AF Registry Investigators, et al. Left atrial thrombus resolution in atrial fibrillation or flutter: results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J. 2016;178:126–34.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, Jean Monnet University, Saint-Etienne Cedex 2, Loire, France

    Jessica Daher, Antoine Da Costa, Christophe Hilaire, Thomas Ferreira, Romain Pierrard, Jean Baptiste Guichard, Cécile Romeyer & Karl Isaaz

  2. Service de Cardiologie, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Etienne, 42055, Saint-Etienne Cedex 2, Loire, France

    Antoine Da Costa

Authors
  1. Jessica Daher
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Antoine Da Costa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christophe Hilaire
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thomas Ferreira
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Romain Pierrard
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jean Baptiste Guichard
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Cécile Romeyer
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Karl Isaaz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Antoine Da Costa.

Ethics declarations

Funding

No funding was received for this study.

Conflict of interest

Jessica Daher, Antoine Da Costa, Christophe Hilaire, Thomas Ferreira, Romain Pierrard, Jean Baptiste Guichard, Cécile Romeyer, and Karl Isaaz have no conflicts of interest related to this study.

Ethical Approval

All procedures in this study were in accordance with the 1964 Helsinki Declaration (and its amendments). No approval was required for this study due to its retrospective design.

Informed Consent

Informed written consent was obtained from patients in order to use their medical information.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Daher, J., Da Costa, A., Hilaire, C. et al. Management of Left Ventricular Thrombi with Direct Oral Anticoagulants: Retrospective Comparative Study with Vitamin K Antagonists. Clin Drug Investig 40, 343–353 (2020). https://doi.org/10.1007/s40261-020-00898-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40261-020-00898-3

Search

Navigation