Rational Pharmacotherapy in Cardiology

Advanced search

Left Ventricular Thrombosis: Current Perspective and Use of Direct Oral Anticoagulants

Full Text:


Left ventricular thrombus (LVT) is a serious risk factor for systemic embolism development. Despite the evident danger of this condition, current guidelines describe management of patients with this potentially fatal complication very briefly. LVT can complicate myocardial infarction where its incidence is around 10%, as well as various forms of cardiomyopathies and novel coronavirus infection. According to clinical guidelines vitamin K antagonists (VKAs) should be used as treatment of choice for thrombus resolution. However, experts point out that this therapy lacks necessary evidential base and bears certain difficulties because of pharmacokinetic and pharmacodynamical properties of VKAs. These drawbacks are absent in direct oral anticoagulants (DOACs), the possibility of using which in LVT is being actively studied. As for now, published results of 3 randomised clinical trials have demonstrated similar safety and efficacy profiles of DOACs and VKAs. Similarly, the majority of retrospective cohort studies did not observe significant differences between two groups, where some of them have shown superiority of DOACs especially in terms of earlier thrombus resolution. Nevertheless, some studies have found DOACs ineffective and even potentially unsafe regarding systemic embolism. Existing data does not allow to form an unambiguous conclusion about the equivalence of DOACs and VKAs for LVT resolution. Large randomised clinical trials are needed to determine efficacy and safety of such treatment in these patients.

About the Authors

A. D. Aga
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Alexandra D. Aga


A. A. Sokolova
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Anastasiya A. Sokolova


D. A. Napalkov
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Dmitry A. Napalkov



1. Ibanez B, James S, Agewall S, et al. ESC Scientific Document Group. 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(2):119-77. DOI:10.1093/eurheartj/ehx393.

2. Kropacheva ES. Intracardiac thrombosis: frequency, risk factors and place of oral anticoagulants in treatment. Atherothrombosis. 2020;(1):134-52 (In Russ.) DOI:10.21518/2307-1109-2020-1-134-152.

3. Habash F, Vallurupalli S. Challenges in management of left ventricular thrombus. Ther Adv Cardiovasc Dis. 2017;11(8):203-13. DOI:10.1177/1753944717711139.

4. 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. DOI:10.1016/j.ijcard.2016.07.069.

5. Pöss J, Desch S, Eitel C, et al. 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. DOI:10.1161/CIRCIMAGING.115.003417.

6. Delewi R, Zijlstra F, Piek JJ. Left ventricular thrombus formation after acute myocardial infarction. Heart. 2012;98(23):1743-9. DOI:10.1136/heartjnl-2012-301962.

7. Roifman I, Connelly KA, Wright GA, Wijeysundera HC. Echocardiography vs. Cardiac Magnetic Resonance Imaging for the Diagnosis of Left Ventricular Thrombus: A Systematic Review. Can J Cardiol. 2015;31(6):785-91. DOI:10.1016/j.cjca.2015.01.011.

8. Weinsaft JW, Kim J, Medicherla CB, et al. A Novel Imaging Algorithm for Post Myocardial Infarction Left Ventricular Thrombus – Regional LV Function on Echocardiography as a Gatekeeper for Thrombus Evaluation by Delayed Enhancement Cardiac Magnetic Resonance. JACC Cardiovasc Imaging. 2016;9(5):505-15. DOI:10.1016/j.jcmg.2015.06.017.

9. Dinesh Kumar US, Shetty SP, Sujay KR, Wali M. Left ventricular mass: A tumor or a thrombus diagnostic dilemma. Ann Card Anaesth. 2016;19(4):728-32. DOI:10.4103/0971-9784.191551.

10. Lemaître AI, Picard F, Maurin V et al. Clinical profile and midterm prognosis of left ventricular thrombus in heart failure. ESC Heart Fail. 2021;8(2):1333-41. DOI:10.1002/ehf2.13211.

11. Hamada M. Left Ventricular Thrombus in Hypertrophic Cardiomyopathy. Intern Med Tokyo Jpn. 2019;58(4):465-7. DOI:10.2169/internalmedicine.1646-18.

12. Becker RC, Owens AP, Sadayappan S. Tissue-Level Inflammation and Ventricular Remodeling in Hypertrophic Cardiomyopathy. J Thromb Thrombolysis. 2020;49(2):177-83. DOI:10.1007/s11239-019-02026-1.

13. Herath HMMTB, Pahalagamage SP, Lindsay LC, et al. Takotsubo cardiomyopathy complicated with apical thrombus formation on first day of the illness: a case report and literature review. BMC Cardiovasc Disord. 2017;17(1):176. DOI:10.1186/s12872-017-0616-0.

14. Ding KJ, Cammann VL, Szawan KA, et al. Intraventricular Thrombus Formation and Embolism in Takotsubo Syndrome: Insights From the International Takotsubo Registry. Arterioscler Thromb Vasc Biol. 2020;40(1):279-87. DOI:10.1161/ATVBAHA.119.313491.

15. Shilova AS, Shmotkina AO, Yafarova AA, Gilyarov MY. Takotsubo Syndrome: Contemporary Views on the Pathogenesis, Prevalence and Prognosis. Rational Pharmacotherapy in Cardiology. 2018;14(4):598-604 (In Russ.) DOI:10.20996/1819-6446-201814-4-598-604.

16. Chimenti C, Lavalle C, Magnocavallo M, et al. A proposed strategy for anticoagulation therapy in noncompaction cardiomyopathy. ESC Heart Fail. 2021;9(1):241-50. DOI:10.1002/ehf2.13694.

17. Pitta S, Thatai D, Afonso L. Thromboembolic complications of left ventricular noncompaction: case report and brief review of the literature. J Clin Ultrasound JCU. 2007;35(8):465-8. DOI:10.1002/jcu.20349.

18. Bakalli A, Georgievska-Ismail L, Koçinaj D, et al. Left ventricular and left atrial thrombi in sinus rhythm patients with dilated ischemic cardiomyopathy. Med Arch Sarajevo Bosnia Herzeg. 2012;66(3):155-8. DOI:10.5455/medarh.2012.66.155-158.

19. Chan NC, Weitz JI. COVID-19 coagulopathy, thrombosis, and bleeding. Blood. 2020;136(4):381-3. DOI:10.1182/blood.2020007335.

20. Giustino G, Pinney SP, Lala A, et al. Coronavirus and Cardiovascular Disease, Myocardial Injury, and Arrhythmia. J Am Coll Cardiol. 2020;76(17):2011-23. DOI:10.1016/j.jacc.2020.08.059.

21. Lala A, Johnson KW, Januzzi JL, et al. Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection. J Am Coll Cardiol. 2020;76(5):533-46. DOI:10.1016/j.jacc.2020.06.007.

22. Nishiga M, Wang DW, Han Y, et al. COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives. Nat Rev Cardiol. 2020;17(9):543-58. DOI:10.1038/s41569-020-0413-9.

23. Diaz-Arocutipa C, Torres-Valencia J, Saucedo-Chinchay J, Cuevas C. ST-segment elevation in patients with COVID-19: a systematic review. J Thromb Thrombolysis. 2021;52(3):738-45. DOI:10.1007/s11239-021-02411-9.

24. Azevedo RB, Botelho BG, Hollanda JVG de, et al. Covid-19 and the cardiovascular system: a comprehensive review. J Hum Hypertens. 2021;35(1):4-11. DOI:10.1038/s41371-020-0387-4.

25. Fenton M, Siddavaram S, Sugihara C, Husain S. Lessons of the month 3: ST-elevation myocardial infarction and left ventricular thrombus formation: an arterial thrombotic complication of severe COVID-19 infection. Clin Med Lond Engl. 2020;20(4):437-9. DOI:10.7861/clinmed.2020-0266.

26. Materna O, Koubský K, Pádr R, Janoušek J. Major left ventricular thrombi in an adolescent with COVID19-associated inflammatory syndrome. Eur Heart J. 2021;42(33):3207. DOI:10.1093/eurheartj/ehab165.

27. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-140. DOI:10.1016/j.jacc.2012.11.019.

28. Guyatt GH, Akl EA, Crowther M, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):7S-47S. DOI:10.1378/chest.1412S3.

29. Abdelnabi M, Saleh Y, Fareed A, et al. Comparative Study of Oral Anticoagulation in Left Ventricular Thrombi (No-LVT Trial). J Am Coll Cardiol. 2021;77(12):1590-2. DOI:10.1016/j.jacc.2021.01.049.

30. Alcalai R, Butnaru A, Moravsky G, et al. Apixaban versus Warfarin in Patients with Left Ventricular Thrombus, A Prospective Multicenter Randomized Clinical Trial. Eur Heart J Cardiovasc Pharmacother. 2022;8(7):660-7. DOI:10.1093/ehjcvp/pvab057.

31. Isa W Y W, Hwong N, Mohamed Yusof AK, et al. Apixaban versus Warfarin in Patients with Left Ventricular Thrombus: A Pilot Prospective Randomized Outcome Blinded Study Investigating Size Reduction or Resolution of Left Ventricular Thrombus. J Clin Prev Cardiol. 2020;9(4):150-4. DOI:10.4103/JCPC.JCPC_41_20.

32. Bass ME, Kiser TH, Page RL, et al. Comparative effectiveness of direct oral anticoagulants and warfarin for the treatment of left ventricular thrombus. J Thromb Thrombolysis. 2021;52(2):517-22. DOI:10.1007/s11239-020-02371-6.

33. Cochran JM, Jia X, Kaczmarek J, et al. Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data. J Cardiovasc Pharmacol Ther. 2021;26(2):173-8. DOI:10.1177/1074248420967644.

34. 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. 2020;40(4):343- 53. DOI:10.1007/s40261-020-00898-3.

35. Durrer-Ariyakuddy K, Moccetti F, Stämpfli S. Direct oral anticoagulants versus vitamin K antagonists for treatment of left ventricular thrombus – insights from multicenter registry. Cardiovasc Med. 2019;22:P27. DOI:10.4414/cvm.2019.02052.

36. Gama F, Freitas P, Trabulo M, et al. Direct oral anticoagulants are an effective therapy for left ventricular thrombus formation. Eur Heart J. 2019;40(Suppl_1):ehz747.0118. DOI:10.1093/eurheartj/ehz747.0118.

37. Guddeti RR, Anwar M, Walters RW, et al. Treatment of Left Ventricular Thrombus With Direct Oral Anticoagulants: A Retrospective Observational Study. Am J Med. 2020;133(12):1488-91. DOI:10.1016/j.amjmed.2020.05.025.

38. Iqbal H, Straw S, Craven TP, et al. Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus. ESC Heart Fail. 2020;7(5):2032-41. DOI:10.1002/ehf2.12718.

39. Jaidka A, Zhu T, Lavi S, Johri A. Treatment of left ventricular thrombus using warfarin versus direct oral anticoagulants following anterior myocardial infarction Can J Cardiol. 2018;34(10):S143. DOI:10.1016/j.cjca.2018.07.194.

40. Willeford A, Zhu W, Stevens C, Thomas IC. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Left Ventricular Thrombus. Ann Pharmacother. 2021;55(7):839-45. DOI:10.1177/1060028020975111.

41. Xu Z, Li X, Li X, et al. Direct oral anticoagulants versus vitamin K antagonists for patients with left ventricular thrombus. Ann Palliat Med. 2021;10(9):9427-34. DOI:10.21037/apm-21-1683.

42. Yunis A, Seese L, Stearns B, et al. Direct oral anticoagulants are effective therapy in treating left ventricular thrombi. J Am Coll Cardiol. 2020;75(11):948. DOI:10.1016/S0735-1097(20)31575-8.

43. Jones DA, Wright P, Alizadeh MA, et al. The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction. Eur Heart J Cardiovasc Pharmacother. 2021;7(5):398-404. DOI:10.1093/ehjcvp/pvaa096.

44. Ali Z, Isom N, Dalia T, et al. Direct oral anticoagulant use in left ventricular thrombus. Thromb J. 2020;18:29. DOI:10.1186/s12959-020-00242-x.

45. Saleh Y, Al-Abcha A, Abdelkarim O, et al. Meta-Analysis Investigating the Role of Direct Oral Anticoagulants Versus Vitamin K Antagonists in the Treatment of Left Ventricular Thrombi. Am J Cardiol. 2021;150:126- 8. DOI:10.1016/j.amjcard.2021.03.032.

46. Saleiro C, Lopes J, De Campos D, et al. Left Ventricular Thrombus Therapy With Direct Oral Anticoagulants Versus Vitamin K Antagonists: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol Ther. 2021;26(3):233-43. DOI:10.1177/1074248420977567.

47. Li S, Deng Y, Tong Y, et al. Assessment of non-vitamin K antagonist oral anticoagulants for the management of left ventricular thrombus. Clin Cardiol. 2021;44(6):754-60. DOI:10.1002/clc.23553.

48. Michael F, Natt N, Shurrab M. Direct Oral Anticoagulants vs Vitamin K Antagonists in Left Ventricular Thrombi: A Systematic Review and Meta-analysis. CJC Open. 2021;3(9):1169-81. DOI:10.1016/j.cjco.2021.04.007.

49. Trongtorsak A, Thangjui S, Kewcharoen J, et al. Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis. Acta Cardiol. 2021;76(9):933-42. DOI:10.1080/00015385.2020.1858538.

50. Kajy M, Shokr M, Ramappa P. Use of Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: Systematic Review of Current Literature. Am J Ther. 2020;27(6):e584-90. DOI:10.1097/MJT.0000000000000937.

51. Tomasoni D, Sciatti E, Bonelli A, et al. Direct Oral Anticoagulants for the Treatment of Left Ventricular Thrombus-A New Indication? A Meta-summary of Case Reports. J Cardiovasc Pharmacol. 2020;75(6):530-4. DOI:10.1097/FJC.0000000000000826.

52. Abdelaziz HK, Megaly M, Debski M, et al. Meta-Analysis Comparing Direct Oral Anticoagulants to Vitamin K Antagonists for The Management of Left Ventricular Thrombus. Expert Rev Cardiovasc Ther. 2021;19(5):427-32. DOI:10.1080/14779072.2021.1915134.

53. Chen R, Zhou J, Liu C, et al. Direct oral anticoagulants versus vitamin K antagonists for patients with left ventricular thrombus: a systematic review and meta-analysis. Pol Arch Intern Med. 2021;131(5):429- 38. DOI:10.20452/pamw.15923.

54. Kido K, Ghaffar YA, Lee JC, et al. Meta-analysis comparing direct oral anticoagulants versus vitamin K antagonists in patients with left ventricular thrombus. PloS One. 2021;16(6):e0252549. DOI:10.1371/journal.pone.0252549.

55. Robinson AA, Trankle CR, Eubanks G, et al. Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi. JAMA Cardiol. 2020;5(6):685-92. DOI:10.1001/jamacardio.2020.0652.

56. Lim CW, Mamat RM, Hishammudin IA, et al. Left Ventricular Thrombus: Patient Characteristics and Treatment from a Single Tertiary Centre’s Experience. Int J Cardiol. 2019;297:20-1. DOI:10.1016/j.ijcard.2019.11.056.

57. Degheim G, Berry A, Zughaib M. Off label use of direct oral anticoagulants for left ventricular thrombus. Is it appropriate? Am J Cardiovasc Dis. 2017;7(5):98-101.

58. Moey MYY, Tomdio AN, Achike O, Kabirdas D. Large Left Ventricular Thrombus as a Cause of Recurrent Cardioembolic Stroke While on Dabigatran. CASE Cardiovasc Imaging Case Rep. 2018;2(5):222-4. DOI:10.1016/

59. Kaya A, Hayıroğlu Mİ, Keskin M, et al. Resolution of left ventricular thrombus with apixaban in a patient with hypertrophic cardiomyopathy. Turk Kardiyol Dernegi Arsivi Turk Kardiyol Derneginin Yayin Organidir. 2016;44(4):335-7. DOI:10.5543/tkda.2015.68054.

60. 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 Reports. 2013;7:238. DOI:10.1186/1752-1947-7-238.

61. Elikowski W, Małek-Elikowska M, Fertała N, et al. Fast apixaban-related resolution of left ventricular thrombi in a patient with dilated cardiomyopathy. Pol Merkur Lek Organ Pol Tow Lek. 2018;44(259): 19-22.

62. 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. Medicine (Baltimore). 2018;97(4):e9670. DOI:10.1097/MD.0000000000009670.

63. Bahmaid RA, Ammar S, Al-Subaie S, et al. Efficacy of direct oral anticoagulants on the resolution of left ventricular thrombus—A case series and literature review. JRSM Cardiovasc Dis. 2019;8: 2048004019839548. DOI:10.1177/2048004019839548.

64. 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. 2018;7(1):135-42. DOI:10.1002/ccr3.1917.

65. Smetana KS, Dunne J, Parrott K, et al. Oral factor Xa inhibitors for the treatment of left ventricular thrombus: a case series. J Thromb Thrombolysis. 2017;44(4):519-24. DOI:10.1007/s11239-017-1560-7.

66. Verma B, Singh A, Kumar M. Use of dabigatran for treatment of left ventricular thrombus: A tertiary care center experience. J Fam Med Prim Care. 2019;8(8):2656-60. DOI:10.4103/jfmpc.jfmpc_459_19.


For citations:

Aga A.D., Sokolova A.A., Napalkov D.A. Left Ventricular Thrombosis: Current Perspective and Use of Direct Oral Anticoagulants. Rational Pharmacotherapy in Cardiology. 2022;18(6):727-733. (In Russ.)

Views: 272

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.

ISSN 1819-6446 (Print)
ISSN 2225-3653 (Online)