Despite the remarkable advancements in cardiovascular medicine, the management of left ventricular (LV) thrombi remains a significant clinical challenge. The lack of robust, universally accepted guidelines, coupled with the inherent complexities of LV thrombus formation, morphology, and risk stratification, contributes to the ongoing uncertainty surrounding optimal diagnostic and therapeutic strategies. This article aims to provide a comprehensive overview of current knowledge regarding LV thrombus, focusing on the role of novel oral anticoagulants (NOACs) in its management, and addressing key aspects including definition, diagnosis, risk assessment, morphology, and emerging treatment approaches.
LV Thrombus Definition:
A left ventricular thrombus (LVT) is defined as an intracardiac thrombus located within the left ventricle of the heart. Its formation is typically associated with significant left ventricular dysfunction, often characterized by reduced ejection fraction (EF) and impaired systolic function. The presence of an LVT significantly increases the risk of systemic thromboembolic events, including stroke, myocardial infarction, and peripheral arterial embolism. The clinical significance of an LVT is directly related to its size, mobility, and the underlying cardiac pathology. Small, immobile thrombi may remain asymptomatic, while larger, mobile thrombi pose a significantly higher risk of embolization.
LV Thrombus Diagnosis:
The definitive diagnosis of an LVT relies primarily on echocardiography, specifically transthoracic echocardiography (TTE) and, in certain cases, transesophageal echocardiography (TEE). TTE is the initial imaging modality of choice due to its non-invasiveness, but its sensitivity in detecting LVTs, particularly smaller or less mobile thrombi, can be limited by acoustic shadowing and poor image quality. TEE, while more invasive, offers superior image resolution and visualization of the left ventricular cavity, making it the preferred method for confirming the presence and characterizing the morphology of an LVT. Cardiac magnetic resonance imaging (CMR) can provide additional anatomical details and assess myocardial viability, but its accessibility and cost often limit its routine use in LVT diagnosis.
LV Thrombus Morphology:
The morphology of an LVT can influence its embolic potential and therapeutic approach. Several morphological classifications exist, but a common distinction is made between mobile and immobile thrombi. Mobile thrombi, characterized by their ability to change position within the left ventricle, pose a significantly higher risk of embolization compared to immobile thrombi, which are firmly attached to the endocardium. Another important morphological feature is the presence of *laminated LV thrombus*. This refers to a thrombus with layered structures, often reflecting periods of thrombus formation and possible partial lysis. The presence of lamination may not necessarily correlate with increased embolic risk but can provide clues about the thrombus's age and stability. The size and location of the thrombus within the left ventricle also contribute to the risk assessment. Apical thrombi are more frequently associated with embolic events compared to thrombi located in other regions of the left ventricle.
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