Resolution of left ventricular thrombus assessed by echocardiography: insights from a contemporary multicentre prospective registry

How to detect and monitor left ventricular thrombus (LVT) remains complex since clinicians can rely only on retrospective, single-centre data. To characterize the incidence and independent associates of LVT resolution (assessed with echocardiography) and its clinical implications on long-term follow-up in a contemporary cohort of consecutive patients with LVT.

Ten centres were involved in this observational prospective multicentre study. The use of different anti-thrombotic regimens and ultrasound contrast was left at the discretion of attending physicians. Echocardiographic follow-up was performed on days 16 ± 8, 48 ± 13, and 132 ± 99 days from LVT detection. Resolution was defined as a complete disappearance of LVT on all echocardiographic views at the last available follow-up. Clinical endpoints included all-cause mortality, embolic complications, and bleeding events. From October 2020 to September 2022, 154 consecutive patients with LVT (mean age 67 ± 11 years, 79% men) were enrolled. Different anti-coagulant regimens were used, and the median duration of anti-coagulation was 6 (3–12) months. LVT resolution was achieved in 68% at a median follow-up of 36 (IQR 15–74) days. At baseline assessment, LVT characteristics like smaller LVT area and mobile LVT were independent predictors of LVT resolution. At follow-up echocardiogram, greater LV global and apical mechanical function were independently associated with LVT resolution (OR, 1.04, 95% CI 1.01–1.07, P = 0.026 for LVEF and 0.94, 95% CI 0.89–0.99, P = 0.025 for apical wall motion score index). During a median follow-up of 1.91 (IQR, 1.32–2.83) years, patients with LVT resolution showed a significantly lower risk of embolic events (adjusted HR, 0.36 95% CI 0.13–0.99, P = 0.04) and death (adjusted HR, 0.36 95% CI 0.14–0.95, P = 0.03) compared with those without resolution. Moreover, LVT resolution was not associated with bleeding complications.

The present longitudinal multicentre registry reveals that LVT persists in nearly one-third of patients after initial detection, even with anti-coagulation therapy, and is associated with a poorer prognosis. Additionally, it offers valuable insights into echocardiographic predictors of LVT persistence, which could inform personalized follow-up strategies and treatment approaches.