Evaluation of the efficacy and safety of rivaroxaban compared to warfarin in patients with left ventricular apical thrombus: a randomized clinical trial.

INTRODUCTION: This research is one of the pioneering randomized clinical trials (RCTs) aimed at assessing the effectiveness and safety of rivaroxaban in treating left ventricular thrombus (LVT) in patients who have experienced acute coronary syndrome (ACS). MATERIALS AND METHODS: This is a randomized, controlled, interventional, open-label study. The patients were randomly divided into warfarin and rivaroxaban groups. We performed transthoracic echocardiography at the start of the study and again after three months to measure the thrombus area in square millimeters. The morphology of the thrombus was categorized into mural and round, and the mobility was classified into immobile, semi-mobile and hypermobile. We also monitored for adverse events including bleeding, systemic embolic occurrences, rehospitalization, and major adverse cardiac events (MACE). RESULTS: The study included fifty-two patients in the intention-to-treat analysis, with an equal split between the rivaroxaban and warfarin groups (26 patients each). The average follow-up duration was three months. The thrombus resolution rates in the rivaroxaban (76.9%) and warfarin (69.2%) groups, as well as the thrombus size reduction, did not show statistical significance between groups. All semi-mobile or hypermobile thrombi transformed into immobile and all of the round LVTs changed into a mural in both rivaroxaban and warfarin groups. No significant difference was observed in bleeding complications and rehospitalization between the two groups. CONCLUSION: The trial demonstrated that rivaroxaban is as effective as warfarin in terms of thrombus resolution rate, reduction in thrombus size, bleeding risk, and rehospitalization rate. Our findings suggest that rivaroxaban is a viable alternative to warfarin for managing left ventricular thrombus.

Apical thrombus mimicking ventricular septal rupture.

A 51-year-old man with chest pain was admitted to the emergency department. The patient was taken to the coronary angiography lab with a diagnosis of inferior myocardial infarction.

The many faces of takotsubo syndrome: A review.

Takotsubo syndrome is a state of an acute heart failure featuring reversible left ventricular dysfunction. In recent years, the incidence of Takotsubo syndrome has risen 8-fold. In this case series and literature review, we present the rare presentations or complications of Takotsubo syndrome and highlight diagnostic or management strategies. We aim to raise the awareness on the pathologic spectrum of takotsubo syndrome for the clinicians encountering this challenging diagnosis.

A Rare Case of Apixaban-Induced Subdural Hematoma in Elderly Heart Failure Patient.

New oral anticoagulants (NOACs) have become more popular in the last few decades. Although apixaban has been proven to be safer than warfarin and causes less hemorrhage in comparison to other NOACs, it still poses a risk of spontaneous bleeding. We present here an 81-year-old male known case of heart failure with reduced ejection fraction (HFrEF) associated with an apical thrombus of 0.93×1.29 cm who presents with cognitive decline, slurred speech, and right side weakness following apixaban use for his apical thrombus. On further evaluation of non-contrast brain computerized tomography (CT), there was a large extra-axial subacute subdural hematoma with thick septations in the left parietal region, measuring 2.6 cm in thickness, causing an a mass effect, and an a midline shift of 1 mm. Following neurosurgery, cardiology, and anesthesiology discussions, the surgery was deferred due to his age and coexisting conditions with regular follow-ups. The patient has now gained full consciousness and is currently undergoing physiotherapy. This case highlights an elderly patient with apixaban-induced subdural hemorrhage, which is a rare entity in the medical literature. Although apixaban is safer than other NOACs, it may cause subdural hemorrhage.

Case report: diagnosis of chronic Chagas cardiomyopathy using a multimodality imaging approach.

Background: In the USA, ∼300 000 people are affected by Chagas heart disease, a growing, but commonly overlooked, public health issue. Chagas as a potential aetiology of dilated cardiomyopathy remains under-recognized. We present a case where multimodality imaging was essential in the diagnosis and management of Chagas heart disease. Case summary: A 54-year-old man, originally from Mexico, presented to the emergency department with chest pain and recurrent syncopal episodes, found to be in haemodynamically unstable ventricular tachycardia (VT) requiring urgent cardioversion. Urgent coronary angiography revealed no obstructive disease. A transthoracic echocardiogram revealed moderately reduced left ventricular systolic function (left ventricular ejection fraction 35-40%) with apical akinesis and an aneurysm of the apical septum. Cardiac magnetic resonance (CMR) confirmed a prominent apical aneurysm with dyskinesis of the apical septum, with the evidence of transmural myocardial late gadolinium enhancement of the entire left ventricular apex and a small apical thrombus. Serologic testing was positive for Trypanosoma cruzi IgG antibody, which was confirmed on repeat testing at the Centers for Disease Control and Prevention. Patient underwent VT ablation and was discharged on guideline-directed medical therapy including a regimen of anticoagulation, beta-blocker, and angiotensin-converting enzyme inhibitor therapies. He has had no subsequent syncope or VT. Discussion: Chagas heart disease remains under-recognized and under-diagnosed despite the growing burden of T. cruzi infection in the USA. Suspicion for Chagas heart disease should be considered in patients presenting with heart failure symptoms and ventricular arrhythmias with the right corresponding history and imaging findings on echocardiogram and CMR.

Eosinophilic myocarditis: Case report and brief review of the literature.

Eosinophilic myocarditis (EM) is a cardiac manifestation of hypereosinophilic syndrome with a high mortality rate. EM shares imaging features similar to other restrictive cardiopathies, and include patchy intramural late gadolinium enhancement on cardiac magnetic resonance with or without presence of biventricular thrombus. Diagnosis is confirmed on histopathology, and is the current gold standard. Here we report clinical presentation and imaging findings of EM in a 70-year-old woman who presented with fever and chills.

The relationship between CHA2DS2VASc score and left ventricular apical thrombus formation in patients with acute anterior ST segment elevation myocardial infarction.

BACKGROUND: Left ventricular apical thrombus (LVAT) formation is a well-known complication of acute anterior myocardial infarction (AMI). The CHA2DS2VASc is a scoring system that has been used to estimate the risk of thromboembolism in patients with nonvalvular atrial fibrillation. This score has also been used for other clinical conditions. The aim of this study was to investigate the relationship between CHA2DS2VASc score and development of LVAT in patients with AMI. METHOD: The study population included 378 patients (mean age: 56.5 ± 12.3 years, male: 318) presenting with AMI between January 2016 and January 2020. Primary percutaneous coronary intervention procedure was performed in all patients. Initial echocardiogram was performed within 7 days of admission. All patients were evaluated with echocardiography at 3rd, 6th and 12th months. Patients were divided into two groups according to the presence of LVAT on echocardiography. RESULTS: The incidence of the LVAT was 8.5% (n = 32) during a mean follow-up time of 233.1 ± 66.7 days. The mean CHA2DS2VASc score was notably higher in patients with LVAT compared to patients in the control group (3.1 ± 1.9 vs. 1.9 ± 1.2, p < 0.001). In Cox regression analysis, high CHA2DS2VASc score, low left ventricular ejection fraction (LVEF) and the presence of LV apical akinesis/aneurysm were the independent predictors for LVAT formation. All of these parameters were associated with higher cumulative incidence of LVAT formation in Kaplan-Meier analyses (p < 0.001 for all). CONCLUSION: High CHA2DS2VASc score, low LVEF and the presence of LV apical akinesis/aneurysm may be used for LVAT risk prediction among patients presenting with AMI.

Concurrent left ventricular and left anterior coronary artery thrombus: is COVID-19 an innocent bystander?

We present the angiographic findings of a case of myocardial infarction associated with COVID-19 with a heavy burden of thrombus, despite only minor obstructive coronary disease.

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients After Anterior Myocardial Infarction.

BACKGROUND: The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction (MI). Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential. We aimed to compare the two-dimensional echocardiography (2DE), contrast-2DE and real-time three-dimensional echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior. METHODS: The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (< 40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and magnetic resonance imaging (MRI) were performed on all patients within one month after anterior MI. RESULTS: Transthoracic 2DE detected thrombi in 29 patients, contrast-2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast-2DE and RT-3DE, respectively. CONCLUSIONS: We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.

COVID-19 Pneumonia Precipitating Acute Anterior Wall Myocardial Infarction With Large Left Ventricular Apical Thrombus.

Initial reports suggest an increased thrombotic risk in coronavirus disease 2019 (COVID-19). We present a case of COVID-19 pneumonia that precipitated chest pain, an acute anterior wall ST-elevation myocardial infarction on the fifth day of hospitalization resulting in large left ventricular apical thrombus.

Management of left ventricular thrombus: a narrative review.

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.

Successful Conservative Treatment of Cardiac Rupture Associated with Takotsubo Syndrome.

We herein report a 75-year-old woman who was diagnosed with Takotsubo syndrome (TTS) complicated by left ventricular outflow tract obstruction on admission. Treatment with beta-blocker and anticoagulant was started; however, her hemoglobin level decreased gradually, and computed tomography performed one week later revealed hemopericardium. Oozing-type cardiac rupture was suspected; therefore, we discontinued heparin treatment. Finally, she recovered uneventfully without cardiac surgery. It is noteworthy that cardiac rupture may occur with TTS, especially in patients treated with prophylactic anticoagulation therapy for apical thrombus. Furthermore, conservative, careful observation is an alternative approach in patients with oozing-type cardiac rupture associated with TTS.

Relationship between apical thrombus formation and blood viscosity in acute anterior myocardial infarction patients.

Aim: This study sought to investigate the predictive value of whole blood viscosity (WBV) to identify high-risk patients who will develop an apical thrombus during the acute phase of anterior transmural infarction. Materials & methods: Consecutive 1726 patients with first acute anterior myocardial infarction were evaluated. WBV was calculated according to the Simone's formula. Results: Patients with an apical thrombus had prolonged pain to balloon time, higher rate of post-PCI thrombolysis in myocardial infarction flow ≤1 and significantly higher mean WBV values at both shear rates than those without an apical thrombus. Conclusion: WBV values at both shear rates were found to be significant and independent predictors for early LV apical thrombus formation complicating a first-ever anterior wall myocardial infarction.

A case report of extramedullary haematopoiesis within left ventricle myocardium and apical thrombus in acute heart failure: diagnosis, treatment, and long-term outcome.

BACKGROUND: Extramedullary haematopoiesis (EMH) within myocardium is a rare phenomenon, and its occurrence in left ventricle myocardium or apical thrombus of a young female has never been reported. CASE SUMMARY: A 23-year-old active female with progressive worsening of dyspnoea. A transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 10-15% and apical thrombus. Bilateral upper extremity Doppler showed deep venous thrombus in the left arm and superficial vein thrombus in both arms. She had reduced activity of antithrombin III, deficiency of protein C and S. Computed tomography of the head showed right thalamic infarct. Having failed optimal medical therapy, rapidly worsening of symptoms (New York Heart Association Class IV and clinical Class C) and cardiogenic shock, she underwent HeartWare® left ventricular assist device (LVAD) placement as a bridge to heart transplant. Intraoperative apical thrombus was carefully extracted while maintaining adequate anticoagulation with heparin infusion. Pathology report of the excised apical myocardium and thrombus demonstrated haematopoietic cells. Twenty-six months since LVAD implantation, she remains active and Status 7 on transplant list (due to body mass index) without any further episodes of thromboembolic events. DISCUSSION: We report an unprecedented case of an active young female with EMH within left ventricular myocardium and apical thrombus. Although redirected differentiation and embolic haematopoietic cells seem to explain this phenomenon, the exact pathophysiology remains unknown. Despite having pre-existing apical thrombus and acute deep vein thrombus, the key towards success was meticulous extraction of apical thrombus while preserving inherent trabecular architecture and adequate anticoagulation.

Simultaneous left and right ventricular apical thrombi after occlusion of the wrapped left anterior descending artery.

Left ventricular (LV) thrombus formation is a well-known complication of acute myocardial infarction (AMI) and is reported to occur in 5-8% of patients who have anterior or apical myocardial infarction. However, right ventricular (RV) thrombus has not previously been reported after AMI. We describe a 54-year-old woman who presented with an ST-elevation myocardial infarction due to occlusion of the distal left anterior descending artery, which wrapped around the apex and led to simultaneous LV and RV apical thrombi. .

Is Rivaroxaban a Safe Choice for Apical Thrombus in Atrial Fibrillation Patients? A Case Report.

Left ventricular thrombi are mostly seen in the akinetic segments of left ventricle and warfarin is the golden standard treatment. In our case, a 67-year-old male patient with ischemic dilated cardiomyopathy and atrial fibrillation was under warfarin treatment, but due to fluctuations in international normalized ratio, warfarin was discontinued and changed to rivaroxaban (20 mg once a day). He had a fixed thrombus measuring 1.80 × 1.12 cm2 in the left ventricle under warfarin treatment before rivaroxaban use. After 6 months of rivaroxaban treatment, the thrombus regressed to 1.54 × 1.06 cm2 without any embolic episode or bleeding. This case supports the finding that rivaroxaban can be a safe alternative to warfarin when warfarin cannot be used.