Management of left ventricular thrombi with direct oral anticoagulants: Retrospective comparative study with vitamin K antagonists

Daher, João Paulo Lima; Costa, Antoine Da; Hilaire, Cynthia St.; Ferreira, Tathiany Jéssica; Pierrard, Romain; Guichard, Jean-Baptiste; Romeyer, Cécile; Isaaz, Karl

doi:10.1016/j.acvdsp.2020.10.167

Cited by 14 publications

(67 citation statements)

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“…Then, three conference abstracts were excluded based on the full text screenings (Table S1). Finally, a total of seven observational retrospective studies that were published in 2020 18‐24 involving 865 patients with left ventricular thrombus ( n = 266 for NOACs and n = 599 for VKAs) were included in this meta‐analysis.…”

Section: Resultsmentioning

confidence: 99%

“…The baseline characteristics of these included studies are shown in Table 1. Five studies used warfarin as the reference, while the combined VKAs, including warfarin, acenocoumarol, and fluindione, were regarded as the control group in the study by Daher et al 20 Specifically, Robinson et al 18 studied a total of 514 patients diagnosed with left ventricular thrombus on echocardiogram, including 236 patients treated with warfarin only and 121 patients treated with NOACs only. In the study by Jones et al, 22 left ventricular thrombus was diagnosed in 101 patients after acute myocardial infarction, which included 60 patients who were started on warfarin and 41 patients who used NOACs.…”

Section: Resultsmentioning

confidence: 99%

“…Guddeti et al 21 retrospectively identified 99 patients with a diagnosis of left ventricular thrombus (80 patients on warfarin and 19 on NOACs). The retrospective study by Daher et al 20 included 59 patients with left ventricular thrombus (42 patients on VKAs and 17 on NOACs). Ali et al 23 identified a total of 110 patients with left ventricular thrombus, but only 32 patients with NOACs and 60 patients with warfarin were included in our meta‐analysis.…”

Section: Resultsmentioning

confidence: 99%

“…Moreover, there are still no direct head‐to‐head randomized clinical trials for this purpose. In recent years, several observational studies have assessed the effect of NOACs relative to that of VKAs in patients with left ventricular thrombus, but the results remain contradictory 18‐24 . Therefore, we quantitatively performed a meta‐analysis of observational studies comparing the effectiveness and safety of NOACs and VKAs on the rates of thrombus resolution and clinical outcomes in patients with left ventricular thrombus.…”

Section: Introductionmentioning

confidence: 99%

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Assessment of non‐vitamin K antagonist oral anticoagulants for the management of left ventricular thrombus

Deng

Tong

et al. 2021

Clinical Cardiology

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Although several studies have assessed the effect of non‐vitamin K antagonist oral anticoagulants (NOACs) relative to that of vitamin K antagonists (VKAs) in patients with left ventricular thrombus, the results remain controversial. Herein, a meta‐analysis was performed to compare the effectiveness and safety of NOACs versus VKAs for the treatment of left ventricular thrombus. We systematically searched the Cochrane Library, PubMed and Embase databases until November 2020 for studies that compared the effects of NOACs versus VKAs in patients with left ventricular thrombus. The treatment effects were expressed as odds ratios (ORs) with 95% confidence intervals (CIs) and pooled by a random‐effects model. Seven retrospective studies involving 865 patients with left ventricular thrombus (266 NOAC and 599 VKA users) were included. The pooled analysis suggested no difference in the rate of thrombus resolution between the NOAC and VKA groups (OR = 0.83, 95% CI 0.61–1.13). There were also no differences in the rates of stroke or systemic embolism (OR = 0.62, 95% CI 0.20–1.97), bleeding events (OR = 0.73, 95% CI 0.37–1.45), or all‐cause death (OR = 0.92, 95% CI 0.50–1.69) between patients treated with NOACs and those treated with VKAs. In addition, the rates of thrombus resolution, stroke or systemic embolism, bleeding events, and all‐cause death between NOAC‐ and warfarin‐treated patients were also similar. Our current evidence suggested that NOAC and VKA users had similar rates of thrombus resolution and clinical outcomes among patients with left ventricular thrombus. Further large‐scale prospective studies should confirm our results.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Assessment of non‐vitamin K antagonist oral anticoagulants for the management of left ventricular thrombus

Deng

Tong

et al. 2021

Clinical Cardiology

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“…In all patients with newly diagnosed ventricular thrombi anticoagulation was initiated with either warfarin with goal INR 2.0–3.0 ( n = 6) or a direct oral anticoagulant (DOAC) ( n = 3). This decision was based on provider/patient preference, and recent evidence suggesting the noninferiority of DOAC versus vitamin K antagonist in the treatment of LV thrombus 9–14 . One of the nine patients was on DOAC therapy for previously diagnosed atrial fibrillation and transitioned to warfarin at the time of ventricular thrombus diagnosis.…”

Section: Resultsmentioning

confidence: 99%

Diagnosis, significance, and management of ventricular thrombi in patients referred for VT ablation

Beavers

Ghannam

Liang

et al. 2021

Cardiovasc electrophysiol

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Introduction In patients with structural heart disease presenting with ventricular tachycardia (VT), detection of ventricular thrombi and subsequent management can be challenging. This study aimed to assess the value of multimodality imaging with cardiac magnetic resonance imaging (CMR), contrast‐enhanced transthoracic echocardiography (TTE), and computed tomography (CT) for thrombus detection as well as a management algorithm geared towards anticoagulation and deferred ablation for patients referred for VT ablation. Methods and results A total of 154 consecutive patients referred for VT ablation underwent preprocedural multimodality imaging with CMR, CT, and TTE. In 9 patients (6%) a new ventricular thrombus was detected and anticoagulation was initiated. Thrombi were detected by CMR in nine patients, by CT in seven patients, and by TTE in two patients. Five patients eventually underwent endocardial VT ablation procedures 6.0 ± 2.0 months after initiation of anticoagulation with one patient also requiring an epicardial approach. Two patients died while on anticoagulation, unrelated to ventricular arrhythmia. Four of five patients were rendered non‐inducible and no testing was performed in 1/5 patients. Areas containing left ventricular thrombi were non‐excitable with pacing. Six of thirty‐two inducible VTs were mapped in close vicinity of ventricular thrombi. No clinical embolic events occurred during the ablation procedures. Conclusions Ventricular thrombus was detected in 6% of consecutive patients with structural heart disease undergoing VT ablation. CMR was the most sensitive modality, while contrast‐enhanced TTE failed to detect the majority of thrombi. Anticoagulation followed by ablation can be safely and successfully performed in patients with ventricular thrombi.

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Systematic review of efficacy of direct oral anticoagulants and vitamin K antagonists in left ventricular thrombus

2022

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Aims Left ventricular thrombus (LVT) increases the risk of thrombotic events and mortality. Vitamin K antagonists (VKAs) used to treat LVT have several known risks, as a result of which direct oral anticoagulant (DOAC) use has recently increased. We aimed to evaluate the safety and efficacy of DOACs and VKAs in treating LVT. Methods and results We searched PubMed, Embase, Cochrane Library trials, and Web of Science databases for studies published before 19 April 2022, involving DOAC versus VKA treatment for patients with LVT. This meta‐analysis comprised 21 studies (total patients, n = 3172; DOAC group, n = 888; VKA group, n = 2284). A statistically significant reduction in bleeding events was observed in patients on DOACs vs. those on VKAs (risk ratio (RR) = 0.73, P = 0.004). Patients on DOACs residing in North American and European regions and those with ischaemic heart disease (IHD) had a significantly lower risk of bleeding events than patients residing in other regions or those with a different LVT aetiology, respectively (RR = 0.78, P = 0.04; RR = 0.38, P = 0.02; and RR = 0.63, P = 0.009). A statistically significant reduction in stroke in patients on DOACs versus VKAs (RR = 0.72, P = 0.03) was observed, and patients on DOACs residing in North America and those with IHD had a significantly lower risk of stroke (RR = 0.73, P = 0.04, and RR = 0.61, P = 0.03, respectively). Compared with VKAs, DOACs are statistically associated with an increase in LVT resolution at 1 month (RR = 1.96, P = 0.008). No statistical between‐group difference in all‐cause mortality (RR = 0.72, P = 0.05), systemic embolism (RR = 0.87, P = 0.74), stroke or systemic embolism (RR = 0.90, P = 0.50), and LVT resolution at the end of follow‐up (RR = 1.06, P = 0.13) was observed. Conclusions Compared with VKAs, DOACs significantly reduce the risk of bleeding events and stroke in LVT patients, but mortality was similar in both groups. The advantages are apparent not only in patients belonging to the predominantly white residential areas such as North American and European regions but also in patients with LVT due to IHD. DOACs show promising effects in treating LVT compared with VKAs.

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Management of left ventricular thrombi with direct oral anticoagulants: Retrospective comparative study with vitamin K antagonists

Cited by 14 publications

References 0 publications

Assessment of non‐vitamin K antagonist oral anticoagulants for the management of left ventricular thrombus

Assessment of non‐vitamin K antagonist oral anticoagulants for the management of left ventricular thrombus

Diagnosis, significance, and management of ventricular thrombi in patients referred for VT ablation

Systematic review of efficacy of direct oral anticoagulants and vitamin K antagonists in left ventricular thrombus

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