Left ventricular thrombus

Left Ventricular Thrombus (LVT) is a condition characterized by the formation of a thrombus (blood clot) in the left ventricle of the heart. This condition is significant due to its potential to lead to serious complications, including stroke and systemic embolization. The left ventricle is crucial for pumping oxygenated blood to the body, and the presence of a thrombus can impede this function and pose a risk of the clot dislodging and traveling to other parts of the body.

Etiology

The formation of a left ventricular thrombus is most commonly associated with myocardial infarction (MI), particularly in cases where there is significant damage to the ventricular wall. Other conditions that can lead to LVT include dilated cardiomyopathy, myocarditis, and conditions that lead to a hypercoagulable state. The loss of contractility and the ensuing stasis of blood flow, combined with endothelial injury and a hypercoagulable state, fulfill Virchow's triad for thrombogenesis in the left ventricle.

Pathophysiology

Following myocardial infarction, the damaged myocardial tissue undergoes necrosis, leading to a change in the texture and contractility of the ventricular wall. This area of akinesis or dyskinesis provides a suitable environment for thrombus formation. The process is further facilitated by the inflammatory response to myocardial injury, which can promote a prothrombotic state.

Clinical Presentation

Patients with left ventricular thrombus may be asymptomatic or present with symptoms related to embolization, such as neurological deficits from a stroke or features of peripheral arterial occlusion. The diagnosis is often made incidentally during echocardiographic evaluation of patients post-myocardial infarction or when investigating for a source of embolism.

Diagnosis

Echocardiography, particularly transesophageal echocardiography (TEE), is the primary diagnostic tool for detecting LVT due to its superior sensitivity and specificity compared to transthoracic echocardiography (TTE). Cardiac magnetic resonance imaging (MRI) can also be used for diagnosis, offering detailed images of the left ventricle and the thrombus.

Treatment

The mainstay of treatment for left ventricular thrombus is anticoagulation. Warfarin has traditionally been the anticoagulant of choice, aiming for an INR of 2-3. However, direct oral anticoagulants (DOACs) are increasingly being used. The duration of anticoagulation therapy is determined based on the resolution of the thrombus, which is monitored through serial imaging studies. In cases where anticoagulation is contraindicated or in the presence of a large, mobile thrombus that poses a high risk for embolization, surgical removal may be considered.

Prognosis

The prognosis of patients with left ventricular thrombus depends on several factors, including the underlying cause, the size and mobility of the thrombus, and the occurrence of embolic events. With appropriate anticoagulation therapy, the risk of embolization can be significantly reduced.

Prevention

Prevention of left ventricular thrombus primarily involves the management of its risk factors, such as prompt and effective treatment of myocardial infarction and the use of anticoagulation in patients with conditions predisposing to thrombus formation.