Left ventricular Thrombus management in current clinical practice: an international survey and narrative review.

Background: the left ventricular Thrombosis is known to be one of the most dangerous and life threatening complications after an acute myocardial infarction, with an incidence which is not so low. Still, there are several areas where consensus and evidence are lacking, as literature’s recommendations are not so clear and unequivocal. The purpose was to obtain an international view of the current everyday clinical practice related to the whole LVT management, with the potential to identify the main areas of consensus and divergence between different centers. Methods: an online questionnaire was distributed in cardiological centers with an email invitation. The addresses were taken from two important cardiological websites. The whole form includes a total of 38 questions concerning LVT’s incidence, diagnosis methods and risk stratification, follow up timing, therapy and prophylaxis. Results: the survey was completed by a total of 104 centers. Risk for the Thrombus formation is stratified by the most of the responders (62,5%) with the main factors recommended by the literature, especially represented by heart motion alterations and parameters at echo, combined with interventional and clinical factors. The 88,4% of the responders assess to the LVT formation with screening methods, starting with the first post revascularization echo, and completed with contrast-echo and cardiac CMR. Still, the 76,9% of the operators declares that don’t follow any flow-chart or protocol, searching for the Thrombus without a precise scheme, as the literature is not clear about this specific theme. When asked about the preferred therapy used after discharge, the 31,7% prescribe DOACs as anticoagulant drugs, meaning that more and more cardiologists prefer their off-label use instead of Vitamin K antagonists, as they are not recommended by the Guidelines. The reasons why most of the operators don’t use DAOCs for this indication, is that there’s a lack of sufficient evidence of their utility, it wouldn’t be refunded by the Health System, and due to the conflicting data existing about it’ safety and efficacy (for the 34,6%, 10,57%, and 5,76% respectively). Another important main point valuated is the possibility to implement a prophylaxis, at the moment not recommended. The 48% of the operators don’t implement any, due to its higher bleeding risk, while the remaining responders do, but only in presence of high risk of Thrombus formation (24%), with risk factors (16,34%) and low bleeding risk profile (6,73%). Also the chosen regimen vary a lot, with DAPT preferred (58,3%) over TAT (41,7%). Conclusions: this survey provided extensive data regarding the clinical practice management of the left ventricular Thrombus of European cardiologists. The findings point out that there are several themes without consensus, due to unclarity of the literature and the poor evidence. The most urgent points to be stressed, are a unified diagnosis and screening protocol, the role of the DOACs for its therapy, and a possible prophylaxis. More studies and data about these aspects are required.