Contrast Echocardiography in Heart Failure: Update 2023.

PURPOSE OF REVIEW: The application of ultrasound-enhancing agents (contrast agents) has improved the accuracy and reproducibility of echocardiography. The review focuses on the currently approved and evolving indications for contrast echocardiography in patients with heart failure, specifically examining clinical studies conducted after the publication of the guidelines in 2017 and 2018. RECENT FINDINGS: The current ASE/EACVI recommendations for contrast echocardiography are based on its accuracy and reproducibility in comparison to non-enhanced echocardiography or other imaging modalities like cardiac MRI. However, tissue characterization remains limited with contrast echocardiography. During the last few years, several studies have demonstrated the clinical impact of using contrast agents on the management of patients with heart failure. There is growing evidence on the benefit of using contrast echocardiography in critically ill patients where echocardiography without contrast agents is often suboptimal and other imaging methods are less feasible. There is no risk of worsening renal function after the administration of ultrasound-enhancing agents, and these agents can be administered even in patients with end-stage renal disease. Contrast echocardiography has become a valuable tool for first-line imaging of patients with heart failure across the spectrum of patients with chronic heart failure to critically ill patients.

Trends in Off-Label Indications of Non-Vitamin K Antagonist Oral Anticoagulants in Acute Coronary Syndrome.

Acute coronary syndrome (ACS) is a leading cause of mortality worldwide. Despite optimal antiplatelet therapy recommendation after ischemic events, recurrent thrombotic complications rate remains high. The recurrent events maybe in part due to increased thrombin levels during ACS which may underscore the need for an additional anticoagulation therapy. Given the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin, they have the potential to prevent thrombus formation, in the presence or absence of atrial fibrillation, but at the cost of increased risk of bleeding. NOACs have also shown a promising efficacy in managing left ventricular thrombus and a potential benefit in avoiding stent thrombosis after percutaneous coronary revascularization. Taken as a whole, NOACs are increasingly used for off-licence indications, and continue to evolve as essential therapy in preventing and treating thrombotic events. Herein, this review discusses NOACs off-label indications in the setting of ischemic coronary disease.

Acute Myocardial Infarction From Embolized Left Ventricular Thrombus in Coronavirus Disease 2019.

A 44-year-old man with a late presentation of coronavirus disease 2019 (COVID-19) pneumonia developed a left ventricular apical thrombus resulting in an asymptomatic anterior myocardial infarction due to extensive thrombosis of the left anterior descending artery. There are increasing reports of thrombotic complications in patients infected with COVID-19. This case highlights the risk of thrombotic events caused by severe acute respiratory syndrome-related corona virus-2 and the associated challenges in management. The objective of this case report is to generate primary literature and raise awareness and appreciation for cardiac manifestations of COVID-19.

Comparative effectiveness of direct oral anticoagulants and warfarin for the treatment of left ventricular thrombus.

Left ventricular (LV) thrombus is a complication of acute endomyocardial injury and chronic ventricular wall hypokinesis, resulting in increased risk of thromboembolic complications. Observational studies support the general safety and efficacy of warfarin for this indication. Limited data exists regarding the use of direct oral anticoagulants (DOACs) for LV thrombus. This retrospective cohort study sought to compare the incidence of thromboembolic events, bleeding rates, and blood product administration in patients receiving a DOAC versus warfarin. A total of 949 patients met inclusion, 180 (19%) received a DOAC and 769 (81%) warfarin. For the primary endpoint of new onset thromboembolic stroke, no difference existed between treatments (DOAC: 7.8% vs warfarin: 11.7%, p = 0.13). When compared to warfarin, no difference existed in the composite of thromboembolic events (33% vs 30.6%, p = 0.53, respectively) or in GUSTO bleeding (10.9% vs 7.8%, p = 0.40, respectively). More patients on warfarin received blood products compared to those taking a DOAC (25.8% vs 13.9%, p < 0.001).DOACs may be an alternative to warfarin for the treatment of LV thrombus based on a retrospective assessment of thromboembolic events and GUSTO bleeding events within 90 days of diagnosis of LV thrombus. However, further prospective studies are warranted.

Use of a single circuit to provide temporary mechanical respiratory and circulatory support in patients with LV apical thrombus and cardiogenic shock.

INTRODUCTION: Techniques to support patients with cardiogenic shock continue to improve. Patients with intracardiac thrombi pose a potential for additional complications. Novel methods of biventricular support are necessary to manage these patients. METHODS: Two patients with refractory cardiogenic shock and left ventricular apical thrombi underwent mechanical circulatory support (MCS) as a bridge to decision, with a left ventricular assist device (LVAD) and extracorporeal mechanical oxygenation (ECMO). Instead of the conventional LV apical cannulation for LVAD, the left atrium (LA) was cannulated. The LA cannula was then integrated with the ECMO circuit via a 'Y' connection to a percutaneous right atrial cannula, enabling optimal drainage of both sides into one circuit through a single CentriMag® pump and ECMO into the aorta. RESULTS: The first patient was converted to a durable LVAD and transplanted, while the second patient was explanted, after demonstrating significant LV recovery. CONCLUSION: We demonstrated the use of MCS as a bridge to decision in patients with LV thrombi, utilizing biatrial cannulation with a 'Y' connection to drain both right- and left-sided circulation through a single circuit and pump.

Oral anticoagulation in patients with left ventricular thrombus: a systematic review and network meta-analysis with reconstructed time-to-event data.

BACKGROUND: Left ventricular thrombus (LVT) is associated with high rates of systemic embolism. Vitamin K antagonists (VKAs) are the only approved treatment for LVT. Although evidence suggests direct oral anticoagulant (DOACs) to be at least equally effective in general, the efficacy of individual DOACs remains unclear. METHODS: A literature search was performed in EMBASE, MEDLINE and Web of Science looking for randomized controlled trials (RCTs) and non-randomized controlled studies of interventions (NRSI) comparing individual DOACs to VKAs for the treatment of LVT. Individual patient data was reconstructed and incorporated in a Bayesian network meta-analysis (NMA) and a Cox frailty regression model. RESULTS: A total of 2545 patients across 19 studies (4 RCTs, 15 NRSI) were included. 1738 received VKAs, 581 received Rivaroxaban, 226 received Apixaban, 82 received Dabigatran and 2 received Edoxaban. LVT resolution was less likely with VKAs compared to Rivaroxaban in the time-to-event analysis (HR 0.66, 95% CI [0.49; 0.91], p = 0.01). There was no difference for other DOACs compared to VKAs. Rivaroxaban reduced ischemic stroke compared to VKAs (OR 0.18, 95% CrI [0.05; 0.49]), other DOACs did not. CONCLUSION: In this NMA, Rivaroxaban showed faster LVT resolution and consecutively lower odds of ischemic stroke than VKAs while Apixaban and Dabigatran showed at least equal efficacy. Given the quality and size of the available studies, these differences between individual DOACs should be acknowledged as hypothesis generating only. Future adequately powered randomized controlled trials are needed to assess possible time-varying effects between individual DOACs.

Safety of dobutamine or adenosine stress cardiac magnetic resonance imaging in patients with left ventricular thrombus.

BACKGROUND: Left ventricular (LV) thrombus formation is a common but potentially serious complication, typically occurring after myocardial infarction. Due to perceived high thromboembolic risk and lack of safety data, stress cardiac magnetic resonance (CMR) imaging especially with dobutamine is usually avoided despite its high diagnostic yield. This study aimed to investigate the characteristics, safety and outcome of patients with LV thrombus undergoing dobutamine or vasodilator stress CMR. METHODS: Patients undergoing stress CMR with concomitant LV thrombus were retrospectively included. Risk factors, comorbidities, and previous embolic events were recorded. Periprocedural safety was assessed for up to 48 h following the examination. Major adverse cardiac events (MACE) 12 months before the diagnosis were compared to 12 months after the exam and between patients and a matched control group. Additionally, patients were followed up for all-cause mortality. RESULTS: 95 patients (78 male, 65 ± 10.7 years) were included. Among them, 43 patients underwent dobutamine (36 high-dose, 7 low-dose) and 52 vasodilator stress CMR. Periprocedural safety was excellent with no adverse events. During a period of 24 months, 27 MACE (14.7%) occurred in patients and controls with no statistical difference between groups. During a median follow-up of 33.7 months (IQR 37.6 months), 6 deaths (6.3%) occurred. Type of stress agent, thrombus mobility, or protrusion were not correlated to embolic events or death. CONCLUSION: The addition of a stress test to a CMR exam is safe and does increase the generally high cardioembolic event rate in LV thrombus patients. Therefore, it is useful to support reperfusion decision-making.

Persistent Prothrombotic State in a Patient With Alström Syndrome.

We present the case of a patient with Alström syndrome who was found to have evidence of a prothrombotic state on autopsy after sudden cardiac death. To the best of our knowledge, this case of persistent prothrombotic milieu is the first described in a patient with Alström syndrome.

A Case of Bilateral Renal Infarct Due to Left Ventricular Thrombus.

Renal infarction is an uncommon illness that can have serious side effects. Patients may be predisposed to the disease by factors including smoking, atrial fibrillation, thrombus, infective endocarditis, myocardial infarction, and prosthetic valves. Patients are most susceptible from 24 hours to 15 days after myocardial infarction, with an increased rate of left ventricular (LV) thrombus development, which raises the probability of thromboembolic events in the cerebrovascular system and might exacerbate morbidity and mortality rate. This can be diagnosed by two-dimensional echocardiography. Different risk factors can contribute to the development of an LV thrombus. Renal infarcts from LV clots are less common but can occur bilaterally in certain situations. A 30-year-old male diagnosed with anterior wall myocardial infarction presented at our hospital and was suspected to have bilateral renal infarcts, possibly due to the LV thrombi. The patient was managed on anti-thrombolytics and was reported to be doing well at a follow-up of one month.

Direct oral anticoagulants compared with warfarin in patients with left ventricular thrombus: a cohort study from China.

Background: Current guidelines recommend vitamin K antagonist (VKA) for left ventricular (LV) thrombus. This study aimed to compare the effectiveness and safety of direct oral anticoagulant (DOAC) and warfarin in Chinese patients with LV thrombus. Methods: Patients with LV thrombus admitted to Beijing Anzhen Hospital of Capital Medical University between January 2018 and January 2022, were enrolled in this cohort study. The primary endpoint was defined as thrombus resolution within 90 days. The secondary endpoints included thrombus resolution within 180 days, major bleeding events, and minor bleeding events. All patients were followed up for at least 90 days after diagnosis of LV thrombus. Patients were divided into the VKA and DOAC groups according to the anticoagulants. Differences in clinical endpoint events between the two groups were compared. Results: This study included 129 and 111 patients in the VKA and DOAC groups, respectively. After adjusting for gender and smoking status, no significant difference was observed in thrombus resolution within 90 days between the VKA and DOAC groups. Additionally, there was no difference between the two groups in the secondary endpoints of thrombus resolution within 180 days, major bleeding, and minor bleeding. In subgroup analysis, rivaroxaban and dabigatran did not show significant differences in primary and secondary endpoints. Conclusions: This study showed no significant difference in thrombus resolution between DOAC and warfarin. DOAC might be an alternative to warfarin for the treatment of LV thrombus. However, further large prospective studies are required to explore the efficacy and safety of DOAC in patients with LV thrombus.

Direct Oral Anticoagulation Versus Warfarin in Left Ventricular Thrombus: Pooled Analysis of Randomized Controlled Trials.

Patients with impaired left ventricular (LV) function can develop LV thrombus, a potentially life-threatening condition due to risk of stroke and embolization. Conventional treatment with vitamin K antagonists (VKAs; e.g., warfarin) puts patients at risk of bleeding, and the use of direct oral anticoagulants (DOACs) appears promising, although data are scant. We searched the published English language literature for randomized controlled trials (RCTs) comparing DOACs with VKAs in LV thrombus. End points were failure to resolve, thromboembolic events (stroke, embolism), bleeding, or any adverse event (composite of thromboembolism or bleeding), or all-cause death. Data were pooled and analyzed in hierarchical Bayesian models. In three eligible RCTs, 141 patients were studied during an average of 4.6 months (53.8 patient-years; n = 71 assigned to DOAC, n = 70 assigned to VKA). A similar number of patients in each treatment arm demonstrated failure to resolve (DOAC: 14/71 vs. VKA: 15/70) and death events (3/71 vs. 4/70). However, patients on DOACs suffered fewer strokes/thromboembolic events (1/71 vs. 7/70; log odds ratio [OR], -2.02 [95% credible interval (CI95 ), -4.53 to -0.31]) and fewer bleeding events (2/71 vs. 9/70; log OR, -1.62 [CI95 , -3.43 to -0.26]), leading to fewer patients on DOACs with any adverse event versus VKAs (3/71 vs. 16/70; log OR, -1.93 [CI95 , -3.33 to -0.75]). In conclusion, pooled analysis of RCT data favors DOACs over VKAs in patients with LV thrombus in terms of both efficacy and safety.

The Dilemma of Use of Anticoagulation in Patients With Heart Failure With Reduced Ejection Fraction and Sinus Rhythm: A Case Report and Literature Review.

Heart failure results in significant morbidity and mortality. Heart failure with reduced ejection fraction (HfrEF) in the absence of atrial fibrillation has been increasingly considered an independent risk factor for ischemic stroke, partly because of the development of left ventricular thrombus and subsequent cardioembolic stroke and partly because of hemodynamic impairment. Here, we present a case of a 60-year-old male with heart failure with reduced ejection fraction, who presented with cardioembolic ischemic stroke. In the investigation to localize the source, he was found to have slow intra-ventricular blood flow, which over shorter periods of follow up lead to the development of left ventricle intra-mural thrombi. Meanwhile, the patient also developed hemorrhagic conversion in the ischemic stroke, which further complicated the choice of anticoagulation. To date, no consensus has been developed on the choice of anticoagulation and clinical criteria for the use of anticoagulation in patients having HfrEF and sinus rhythm. This case brings forth a need for further research on whether anticoagulation would be beneficial in patients with HfrEF and sinus rhythm.

Identifying the Cause of Acute Left-Sided Visual Loss: A Clinical Dilemma.

Given the global increase in the incidence of head and neck cancers over the last decade, the use of chemoradiation has also increased. It is well known that chemotherapy/radiation are established standard therapies in head and neck cancers, especially in patients who are not candidates for surgery. Despite this increase in chemoradiation therapies in head and neck cancers, there is a lack of established guidelines on the surveillance and screening of these patients for long-term complications. We present an interesting case of acute left eye blindness in a veteran patient with a history of laryngeal cancer status post chemoradiation and in the setting of a left ventricular (LV) thrombus on anticoagulation resulting in a diagnostic challenge determining the etiology. This case emphasizes the need for thorough patient-centered annual evaluation, thus providing an opportunity for early noninvasive or minimally invasive intervention.

An Updated Review of the Efficacy and Safety of Direct Oral Anticoagulants in Treatment of Left Ventricular Thrombus.

Left ventricular (LV) thrombus is a potentially serious complication affecting males and females with ischemic and nonischemic cardiomyopathy-specifically, after acute myocardial infarctions of the anterior left ventricular wall and long-standing tachyarrhythmias, respectively. LV thrombi pose significant risks for systemic embolization and devastating stroke events, while also demanding a treatment carrying inherent risks of its own. It is therefore imperative to have accurate detection of these ventricular thrombi and an appropriate understanding of the risks and benefits regarding management. Anticoagulation using warfarin has long been established as the gold-standard level of care in the current guidelines of the American College of Cardiology but the advent of direct oral anticoagulants (DOACs) prompts a re-examination of the literature. The particular question we seek to answer lies in the efficacy of these drugs and the safety and outcomes when used to treat LV thrombi. Recent case reports, meta-analyses, and most recently, the breakthrough of 2 novel randomized controlled trials have shown DOACs to be a promising treatment for LV thrombus. Contrarily, some retrospective cohort reviews suggest less-than-promising outcomes. This meta-analysis hopes to provide a current, curated review of up-to-date safety and efficacy in the documented tales of DOACs and LV thrombi that has been published since early 2020-by selecting these curated case studies, and analyzing the most recent randomized controlled trials, we hope to engage the reader with clearer illustrations of the key components of both the advocacy and warning of this pharmaceutical intervention.

Young mother with lupus and life-altering cardiocerebrovascular nightmare: a case report.

Background: Systemic lupus erythematosus (SLE) predominantly affects women and increases their cardiovascular disease risk up to three-fold. Young women with SLE face various challenges and gender-specific issues, especially concerning pregnancy. Case summary: A female patient, 37 years old, married with two children, hospitalized for SLE, consulted for chest pain, shortness of breath, and dry cough. She quit her medication in the past 7 years prior to her admission in the hope of conceiving. Physical examinations showed signs of heart failure. Electrocardiogram revealed recent myocardial infarction. She had increased hs-Troponin T 180.3 pg/mL and NTproBNP 13 419 ng/L. An echocardiogram demonstrated a low ejection fraction at 30.4%, left ventricle thrombus, and wall motion abnormalities. The angiogram showed severe coronary artery disease. Her condition was then complicated by embolic stroke and recurrent bleeding from anticoagulant subcutaneous punctured sites. Discussion: Patients with SLE are prone to hypercoagulability and accelerated atherosclerosis, which may lead to pre-mature mortality. In this case, balancing risk for bleeding vs. ischaemia is a see-saw decision. The current risk scores do not cater specifically to this population, but the existing ones suggest this patient will have an equally undesired outcome. Hence, a multi-disciplinary team discussion was needed. Considering the immense risk of any intervention at the time, the decision was to administer a conservative treatment. Conclusion: Recognizing and anticipating gender-specific issues in managing patients with SLE are keys to preventing catastrophic complications. Multi-disciplinary team involvement is critical in dealing with complex cases.

A Giant Left Intraventricular Thrombus Associated With Apical Hypertrophic Cardiomyopathy Mimics Cancer.

Hypertrophic cardiomyopathy (HCM) is a common disease that can be acquired due to chronic hypertension or via autosomal dominant inheritance. Several patterns of HCM have been described, of which a rare variant is apical hypertrophic cardiomyopathy (AHCM). Atrial thrombus is a well-recognized complication of HCM especially in the setting of atrial fibrillation (AF). However, left ventricular thrombus (LVT) formation is not nearly as prevalent as atrial thrombus. Here is a case of a 57-year-old Hispanic female with AHCM who presented with significant unintentional weight loss and unexplained anemia and was subsequently found to have a large left intraventricular mass suspicious for a tumor vs. ventricular thrombus. The diagnosis was complicated due to the large size of the mass and presenting symptoms suspicious of malignancy.

Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis.

BACKGROUND: Current guidelines recommend vitamin K antagonists (VKAs) to reduce the risk of systemic thromboembolic (STE) events in patients with left ventricular (LV) thrombus. Direct oral anticoagulants (DOACs) are an emerging alternative to VKAs; however, data supporting DOAC use in LV thrombus are still lacking. We conducted this systematic review and meta-analysis to compare the efficacy and safety between DOACs and VKAs in this population. METHODS: We searched MEDLINE, Embase, and the Cochrane Library databases from inception to October 2020 to identify studies that compared clinical outcomes of interest, including stroke or any STE, LV thrombus resolution, and bleeding, between patients who used DOACs and VKAs for LV thrombus. Data from each study were combined using the random-effects model. RESULTS: Eight cohort studies with a total of 1771 patients (426 in DOAC group, 1345 in VKA group) were included. There were no statistically significant differences between VKA group and DOAC group on rates of STE events (pooled RR = 1.12, 95% confidence interval [CI]: 0.91-1.39, p = .286), LV thrombus resolution (pooled RR = 1.09, 95% CI: 0.94-1.27, p = .242), or bleeding events (pooled RR = 0.94, 95% CI: 0.59-1.51, p = .808). CONCLUSIONS: Our meta-analysis found no significant differences in rates of STE events, LV thrombus resolution, or bleeding events between the use of DOACs and VKAs in LV thrombus. Further randomised controlled trials are needed to confirm our findingsHighlightsThere is limited evidence comparing the use of direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in left ventricular (LV) thrombus.Our systematic review and meta-analysis showed that DOACs are not inferior to VKAs in the incidence of systemic thromboembolism (STE), the rate of LV thrombus resolution, and the risk of bleeding.Current evidence is based on observational studies only. Further randomised controlled trials are needed to confirm the findings.

Left ventricular thrombus complicated by acute limb ischemia in a patient with HIV.

Left ventricular thrombus typically occurs in patients with impaired left ventricular function such as aneurysm, dilated cardiomyopathy, or post-myocardial infarction. Untreated HIV infection is known to increase the risk of venous thromboembolism and cardiovascular disease. However, the pathophysiology remains uncertain; some studies have proposed chronic inflammation as the underlying etiology. Nonetheless, left ventricular thrombus is extremely rare among persons living with HIV with no known underlying cardiac disease. Herein, we report an unusual case of a 55-year-old homeless and heterosexual male with past medical history of HIV, who has mildly reduced left ventricular function and a nonmobile, medium size left ventricular thrombus. Patient was initially treated with therapeutic dose of enoxaparin, and subsequently developed acute embolic occlusion of right femoral artery that lead to an above knee amputation. To our knowledge, left ventricular thromboembolism complicated with acute embolic ischemia in persons living with HIV is extremely rare. The presenting case will definitely add to the current body of knowledge and will raise awareness among physicians, in recognizing the rare association between HIV and arterial thromboembolism.

Heart broken. An unusual case of biventricular takotsubo cardiomyopathy complicated by STEMI and Left ventricular thrombi. A case report.

Takotsubo cardiomyopathy (TCM) is a rare occurrence in patients with troponin-positive acute coronary syndrome (ACS). It usually manifests as transient apical ballooning of the left ventricle with concomitant occurrence of right ventricular involvement in only one-third of cases. Biventricular TCM is associated with more hemodynamic instability as compared to left sided alone. Depressed ventricular systolic function and localized ventricular dyskinesis can facilitate clot formation in ventricular cavity. We present a case of 80-year-old man who presented to the ED for evaluation of hypotension. An electrocardiogram suggested acute anterior wall myocardial infarction. He underwent emergent coronary angiography and was found to have mid to apical akinesis and basal hyperkinesis with normal left coronaries and chronic total right coronary artery occlusion with excellent collaterals from left. A transthoracic echocardiography (TTE) revealed left ventricular ejection fraction 25-30% and akinesis of left and right ventricle except in the basal region. TTE with definity showed sessile thrombus. In our patient, sepsis was the most important triggering factor given initial presentation of hypotension with leukocytosis. Broad spectrum antibiotics including vancomycin and Zosyn were started considering a combination of septic and cardiogenic shock. Repeat EKG showed resolution of ST-T segment elevation but our patient remained hemodynamically unstable even with two pressure support and, ultimately, died 72 hours after admission. Herein, we emphasize on the importance right ventricular involvement and its relation to hemodynamic instability. This case highlights the importance of anticipating hemodynamic instability and clot formation in patients with biventricular Takotsubo cardiomyopathy.

Giant Left Ventricular Papillary Fibroelastoma Presented as Transient Ischemic Attack and Complicated by Post-Pericardiotomy Syndrome.

Papillary fibroelastoma is a benign cardiac tumour that most commonly presents as an incidental finding on imaging but may present with an acute neurological event due to embolic phenomena. We report a 51-year-old female who presented with focal neurology of the right hand that lasted for 30 minutes. Her initial investigations including CT-brain were unremarkable, and given her low-risk profile for stroke she was discharged for routine outpatient workup of possible transient ischaemic attack. Transthoracic echo detected a large mobile mass attached to the left ventricular wall. This was mistakenly diagnosed as a left ventricular thrombus, for which she was commenced on warfarin. After three months on warfarin without reduction in the size of the mass, cardiac MRI was performed. The scan was repeated as the initial imaging failed to demonstrate the tumour. This was followed by positron emission tomography which suggested a benign mass of the left ventricle. The patient underwent surgical excision of the tumour and developed post-pericardiotomy syndrome. Histopathology confirmed papillary fibroelastoma. Though rare, cardiac neoplasm may remain a differential diagnosis for acute neurological presentations in non-classical patients.