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Published on: June 11, 2019
Clinical profile and midterm prognosis of left ventricular thrombus in heart failure
Anne-Iris Lemaître1, François Picard1, Vincent Maurin1
1Bordeaux University Hospital (CHU), Bordeaux, France.
Insights
Patients with left ventricular thrombus (LVT) face a 20% risk of death or embolic events within one year, necessitating careful initial management. However, most experience favorable cardiac remodeling, especially those with dilated cardiomyopathy (DCM).
Area of Science:
- Cardiology
- Cardiovascular Medicine
- Medical Prognosis
Background:
- Left ventricular thrombus (LVT) is a serious complication in heart failure (HF) patients, particularly those with reduced ejection fraction.
- Dilated cardiomyopathy (DCM) and ischaemic cardiomyopathy (ICM) are common causes of HF associated with LVT.
- Understanding the midterm prognosis and risk factors for LVT is crucial for effective patient management.
Purpose of the Study:
- To characterize patients with LVT in the context of HF with reduced ejection fraction (LVEF ≤40%).
- To evaluate the midterm risk of death and/or embolic events in LVT patients, stratified by aetiology (ischaemic vs. non-ischaemic).
- To identify risk factors for LVT development in patients with DCM.
Main Methods:
- Retrospective analysis of 105 HF patients diagnosed with LVT between 2005 and 2018.
- Exclusion of patients with significant valve disease, heart transplant, LVAD, congenital heart disease, or acute myocardial infarction.
- Primary endpoint: 1-year risk of all-cause mortality (ACM) and symptomatic embolic events; secondary analysis of LVT risk factors in DCM.
Main Results:
- The 1-year composite risk of ACM and symptomatic embolic events was 20% (15% embolic events, 6% ACM), with no significant difference between DCM and ICM.
- All embolic events occurred within 30 days of LVT diagnosis.
- Left ventricular reverse remodeling occurred in 65% of patients, more frequently in DCM (86%) than ICM (65%).
- Elevated BNP levels were significantly associated with LVT in DCM patients (2447 pg/mL vs. 347 pg/mL).
Conclusions:
- Patients with LVT exhibit high natriuretic peptide levels and face a substantial 1-year risk of embolic events or death despite anticoagulation.
- Prompt recognition and management of LVT are critical, as all embolic events occurred within the first 30 days.
- The majority of LVT patients achieve favorable cardiac remodeling, particularly those with DCM.
Aims:
We documented the midterm prognosis of left ventricular thrombus (LVT) in heart failure (HF) patients with dilated cardiomyopathy (DCM) and ischaemic cardiomyopathy (ICM). We aimed to characterize patients with LVT in the context of HF with reduced (≤40%) left ventricular ejection fraction and evaluate their risk for death and/or embolic events, overall, and specifically in patients with ischaemic or non-ischaemic aetiology. We also intended to identify risk factors for LVT in patients with DCM.
Methods And Results:
We included all HF patients (N = 105, age 56 ± 13) admitted from 2005 to 2018 in our institution for LVT without significant valve disease/prosthesis, heart transplant/left ventricular assist device, congenital heart disease, or acute myocardial infarction. Our primary endpoint was the 1 year risk of the composite of all-cause mortality (ACM) and symptomatic embolic events. Mean left ventricular ejection fraction was 23 ± 9%, and median BNP was 1795 pg/mL. Most (97%) patients were treated with vitamin K anticoagulants, and 64% had ICM. Symptomatic embolic events and/or ACM occurred in 20% of the population [embolic events (all within 30 days of LVT diagnosis) 15% and ACM 6%] and was similarly frequent in DCM or ICM (P > 0.05). Suspected/transient embolic events were more frequent in DCM (overall 13%; 29% in DCM vs. 5% in ICM, P < 0.01). Major bleeding occurred in 5% of patients. Left ventricular reverse remodelling occurred in 65% of patients, more frequently in DCM (86% in DCM vs. 65% in ICM, P = 0.02). In a case-control analysis matching DCM patients, BNP level was the only factor significantly associated with LVT (2447 pg/mL in LVT vs. 347 pg/mL, P < 0.001).
Conclusions:
Patients with LVT have markedly high natriuretic peptides and experience a 20% 1 year risk for embolic events and/or death following diagnosis despite anticoagulant treatment. Most patients have favourable remodelling/recovery. As all symptomatic embolic events occurred within 30 days of LVT diagnosis, a very careful initial management is warranted.
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