Left ventricular thrombus formation after first anterior wall acute myocardial infarction

The characteristics of the left ventricle and coronary arteries associated with left ventricular (LV) thrombus in patients with recent anterior acute myocardial infarction were defined. Of 77 patients studied, 35 (46%) had LV thrombi. The presence of LV thrombus was not correlated to the extent of coronary artery disease. The frequency of LV thrombus progressively increased with groups of increasing wall motion abnormality as determined by the extent of akinesia and dyskinesia (%AD) (%AD 0 to 14, thrombus present in 3 of 16 [19%], %AD 15 to 29, thrombus in 8 of 27 [30%]; %AD greater than or equal to 30%, thrombus in 24 of 34 [71%]; p less than 0.001) and with increasingly severe degrees of early ventricular shape change (normal or mildly abnormal contour, 16% with thrombus; moderately abnormal contour, 36% with thrombus; severely abnormal contour, 70% with thrombus; p less than 0.001). Patients with thrombi had higher diastolic (249 +/- 55 vs 225 +/- 48 ml; p less than 0.05) and systolic (158 +/- 48 vs 120 +/- 45 ml; p less than 0.001) volumes than patients without thrombi, respectively. A stepwise discriminant analysis identified ejection fraction, extent of early shape change and LV end-diastolic pressure as independent correlates of LV thrombus after acute myocardial infarction.     

Influence of thrombolytic therapy on the incidence of left ventricular thrombi after acute anterior myocardial infarction: role of successful reperfusion.

BACKGROUND: Previous studies have reported controversial results regarding the effectiveness of systemic thrombolysis in preventing left ventricular (LV) thrombus after acute myocardial infarction (MI). HYPOTHESIS: This study was performed to evaluate the influences of thrombolysis, and particularly successful reperfusion, on the incidence of LV thrombus formation after acute anterior MI. METHODS: In all, 191 patients suffering from a first attack of acute anterior MI were prospectively evaluated by two-dimensional echocardiography and coronary angiography, performed at the end of the first week and within the first two weeks of MI, respectively. Of these, 98 who presented within 12 h of onset of symptoms received intravenous streptokinase (1.5 million IU), while the remaining 93 patients who, either because of contraindications or late admission, did not receive thrombolytic treatment served as control group. All patients received aspirin and full-dose anticoagulation with intravenous heparin. Successful reperfusion in the streptokinase group was assessed by enzymatic and electrocardiographic evidence. RESULTS: The overall incidence of LV thrombi was 24.6% (47/191). When all patients were evaluated, no statistically significant difference was found between the frequency of LV thrombi in the patients who had thrombolysis (22.4%) and those who did not (26.8%), despite a trend toward the formation of fewer thrombi in the initial group (p > 0.05). However, the patients who had successful reperfusion with streptokinase (n = 64) had significantly reduced incidence of LV thrombi compared with those who did not receive thrombolytic therapy (20 vs. 26.8%, p < 0.05). Stepwise multivariate analysis suggested that LV abnormal wall motion score (p = 0.01) and presence of LV aneurysm were independent predictors of LV thrombus formation in patients with acute anterior MI. CONCLUSION: Not all patients who received streptokinase for acute anterior MI, but only those with successful reperfusion had reduced incidence of LV thrombi. The favorable effects of thrombolysis on LV thrombus formation are probably due to the preservation of global LV systolic function.     

Left ventricular thrombi after short-term high-dose anticoagulants in acute myocardial infarction

To examine the effect of short-term, high-dose anticoagulationon the subsequent occurrence of left ventricular (LV) thrombiafter a first anterior wall acute myocardial infarction (AMI),21 patients received placebo and 21 high-dose anticoagulantsduring the first 10 days of the acute infarction. They werestudied with cross-sectional echocardiography 10 days and 1-3and 6 months post infarction. At 1 month, 6 of 7 thrombi presentin the placebo group at 10 days were still visible. No thrombiwere detected at 10 days in the anticoagulation group, but 6patients had developed a LV thrombus at 1 month. These 12 patientswith LV thrombi were subsequently treated with oral warfarinfor 2 months, after which all thrombi had disappeared. Warfarinwas then discontinued, and a thrombus had recurred in 5 patientsafter 6 months. Apical akinesis at 10 days a predictor for thrombuswith a sensitivity and specificity of 100% and 72.2% respectively. Three of the 13 patients with LV thrombi suffered stroke incontrast to none without thrombi (P=0.025). We conclude that after discontinuation of short-term high-doseanticoagulation therapy in anterior AMI, LV thrombi may developrapidly and lead to embolic complications, particularly in patientswith persisting apical akinesis.     

Left ventricular thrombi after short-term high-dose anticoagulants in acute myocardial infarction

To examine the effect of short-term, high-dose anticoagulationon the subsequent occurrence of left ventricular (LV) thrombiafter a first anterior wall acute myocardial infarction (AMI),21 patients received placebo and 21 high-dose anticoagulantsduring the first 10 days of the acute infarction. They werestudied with cross-sectional echocardiography 10 days and 1-3and 6 months post infarction. At 1 month, 6 of 7 thrombi presentin the placebo group at 10 days were still visible. No thrombiwere detected at 10 days in the anticoagulation group, but 6patients had developed a LV thrombus at 1 month. These 12 patientswith LV thrombi were subsequently treated with oral warfarinfor 2 months, after which all thrombi had disappeared. Warfarinwas then discontinued, and a thrombus had recurred in 5 patientsafter 6 months. Apical akinesis at 10 days a predictor for thrombuswith a sensitivity and specificity of 100% and 72.2% respectively. Three of the 13 patients with LV thrombi suffered stroke incontrast to none without thrombi (P=0.025). We conclude that after discontinuation of short-term high-doseanticoagulation therapy in anterior AMI, LV thrombi may developrapidly and lead to embolic complications, particularly in patientswith persisting apical akinesis.     

Two-dimensional echocardiographic appearance of left ventricular thrombi with systemic emboli after myocardial infarction

To test the hypothesis that left ventricular (LV) thrombi that project into the lumen and are mobile are more likely to embolize than those that do not have these characteristics, the 2-dimensional echocardiograms of 16 patients with LV thrombi after myocardial infarction were retrospectively reviewed. Ten had evidence of peripheral embolization and 6 did not. The studies were reviewed in random order by an observer blinded to the clinical data. Each echocardiogram was graded as showing a protruding or nonprotruding thrombus and the presence or absence of increased mobility. The thrombus projected into the lumen on the echocardiograms of 8 of 10 patients who had had emboli and in 0 of 6 who had not. The thrombus had increased mobility in 4 of 10 patients with emboli and 0 of 6 without. Thus, LV thrombi that project into the lumen and have increased mobility are more likely to embolize than those without these characteristics.     

Frequency of left ventricular thrombus in patients with anterior wall acute myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy

The aim of the present study was to investigate the prevalence of left ventricular (LV) thrombus formation and important determinants in patients with acute ST elevation myocardial infarction localized to the anterior wall treated with percutaneous coronary intervention (PCI) and dual-antiplatelet therapy. One hundred selected patients with ST elevation myocardial infarctions revascularized with PCI in the left anterior descending coronary artery were included. The patients participated in the Autologous Stem Cell Transplantation in Acute Myocardial Infarction (ASTAMI) trial. All were treated with aspirin 75 mg/day and clopidogrel 75 mg/day and underwent serial echocardiography and magnetic resonance imaging during the first 3 months after PCI. After 4 to 5 days, the ejection fraction and infarct size in percentage of the left anterior descending coronary artery area were assessed using single photon-emission computed tomography in addition to the ejection fraction by echocardiography. LV thrombi were detected in 15 patients during the first 3 months, 2/3 of them within the first week. No differences in baseline characteristics between the groups with and without LV thrombi were shown. However, in the thrombus group, significantly higher peak creatine kinase levels (6,128 vs 2,197 U/L, p <0.01), larger infarct sizes (82.5% vs 63.8%, p <0.01), and lower ejection fractions on single photon-emission computed tomography (35.5% vs 40.0%, p = 0.03) and on echocardiography (43.0% vs 46.0%, p = 0.03) were found compared to patients without LV thrombi. In conclusion, LV thrombus formation is a frequent finding in patients with anterior wall ST elevation myocardial infarction treated acutely with PCI and dual-antiplatelet therapy and should be assessed by echocardiography within the first week.     

Prophylactic anticoagulation for left ventricular thrombi after acute myocardial infarction: a prospective randomized trial

Thirty patients with a first episode of an anterior acute myocardial infarction (AMI) without a history of cardiac disease were prospectively randomized into a prophylactic heparin-treated group (group I) and a control nonanticoagulated group (group II) within 12 hours of the onset of chest pain to determine the effectiveness of anticoagulation for preventing left ventricular (LV) thrombi. Serial two-dimensional echocardiograms were performed during the hospital stay and patients were followed clinically for systemic emboli for 1 month after discharge from the hospital. Thirty-one percent of patients in group I (4/13) and 35% of patients in group II (6/17) developed LV thrombi on two-dimensional echocardiograms. There was no statistical difference in the incidence of LV thrombi between the two groups (p greater than 0.05). Infarct size as determined by creatine phosphokinase isoenzymes (2,386 +/- 1,568 vs 2,083 +/- 1,462 IU for groups I and II, respectively; p greater than 0.05), wall motion score (12.7 +/- 5 vs 10.7 +/- 5 for groups I and II, respectively; p greater than 0.05) and wall motion index (1.8 +/- 0.6 vs 1.8 +/- 0.56 for groups I and II, respectively; p greater than 0.05) were not statistically different between the two groups of patients. One patient in both groups had an embolic event. In conclusion, prophylactic anticoagulation in high-risk AMI patients for LV thrombus development does not prevent LV thrombus formation during the acute and subacute stages of an AMI. The results also suggest that anticoagulation may not prevent systemic embolization.     

Predictors of left ventricular thrombus formation in acute myocardial infarction treated with successful primary angioplasty with stenting

BACKGROUND: There are limited data referring to the incidence of left ventricle (LV) thrombus formation after successful primary percutaneous coronary intervention (PCI) with stenting, which is now the treatment of choice in patients with acute myocardial infarction (AMI). Previously reported results were often based on low or heterogeneous patient populations. METHODS: To evaluate the prevalence of LV thrombus in the early period of AMI, 2,911 patients who had undergone successful primary stenting were retrospectively studied. Baseline demographic characteristics, angiographic findings, and antiplatelet treatment were analyzed to find predictors of thrombus formation. LV thrombus was diagnosed by 2-dimensional echocardiography within 3 to 5 days after PCI. RESULTS: This complication was detected in 73 patients (2.5%). Patients with thrombus and patients without it were at the same age and had diabetes mellitus, prior myocardial infarction, and lipid disorders at the same frequency. The extent of coronary artery disease was similar in both groups. The incidence of LV thrombi was similar in patients treated with and without glycoprotein IIb/IIIa inhibitors (2.02% vs 2.9%, NS). According to results of multiple log-regression analysis, the presence of LV thrombus was strongly associated with anterior AMI, ejection fraction <40%, and previous hypertension. CONCLUSIONS: The incidence of left ventricular thrombus early after AMI is very low if primary PCI with stenting is successful, probably due to the salvage of myocardium at risk. Localization of AMI and the size of myocardium damage remain the most important independent predictors of LV thrombus formation irrespective of various treatments.     

Prognostic usefulness of left ventricular thrombus by echocardiography in dilated cardiomyopathy in predicting stroke, transient ischemic attack, and death

Echocardiograms of 290 patients with dilated cardiomyopathy (ejection fraction < or =35%) were reviewed for the presence of left ventricular (LV) apical abnormalities; outcomes of stroke and death were then correlated with the presence of LV thrombus. During a follow-up of 31 months, 15 patients had a stroke or transient ischemic attack after the index echocardiogram (5.2%). Patients with LV thrombus on echocardiography had a significantly higher rate of stroke (adjusted odds ratio 3.4, p = 0.027) than those without echocardiographic evidence of thrombi. There was no difference in mortality between patients with and without thrombus (20.9% vs 21.1%, p = 0.726).     

Uncommon intraventricular thrombus formation between the posterior mitral leaflet and the lateral left ventricular wall

Transthoracic echocardiography demonstrated an intraventricularmass between the posterior mitral leaflet and the lateral leftventricular (LV) free wall in a 61-year-old man. Because ofthis uncommon localization an intracardial tumor, an endocarditisof the mitral valve or an intraventricular thrombus was suspected.Magnetic resonance imaging (MRI) ruled out an intracardial tumorand revealed a myocardial scarring of the LV free wall coveredby an intraventricular thrombus by late gadolinium enhancement.MRI can distinguish subacute clots—which do not enhanceafter contrast material injection—from organized thrombi.The characterization of thrombi can be used to predict the riskof embolism, which is higher for subacute clots than for organizedthrombi.     

Incremental value of live/real time three-dimensional transthoracic echocardiography in the assessment of left ventricular thrombi

This is a case series on three adult patients who contain left ventricular (LV) thrombus and the incremental benefits of live/real time three-dimensional transthoracic echocardiography (3DTTE) in comparison to two-dimensional transthoracic echocardiography (2DTTE) in evaluating LV thrombi. These cases illustrate that 3DTTE is of additional benefit by demonstrating the following: (1) cropping of a single 3DTTE apical dataset may be enough to provide comprehensive assessment of the LV in a timely manner even without breath holding in a not fully cooperative patient (2) it identifies the exact point of attachment of the thrombus to the left ventricular wall, (3) helps to delineate the absence or presence of focal echolucent areas within thrombi indicative of the presence and extent of clot lysis, which may have potential therapeutic and prognostic implications, and (4) provides more accurate assessment of thrombus mobility which has prognostic indications.     

2-dimensional echocardiographic diagnosis of an intracardiac thrombus in children

Eight cases of intracardiac thrombi in infants and children were compiled in a cooperative study involving five paediatric cardiological centres. Two babies were hospitalised for cardiac failure due to a severe supraventricular arrhythmia. Two-dimensional echocardiography (2D echo) showed a left atrial thrombus which disappeared after anticoagulant therapy. The third case was unusual: 2D echo performed 4 months after a Senning operation for complete transposition of the great arteries showed stenosis of the pulmonary venous canal and a thrombus above the stenosis: the mass was echogenic, rounded, of variable density and in contact with the pulmonary veins. These findings were confirmed at autopsy. The fourth case was a 34 month old child with Fallot's triad in whom 2D echo showed a right ventricular thrombus, confirmed at surgery. The four remaining cases were thrombi detected in patients with congestive cardiomyopathy. The thrombus was adherent to the left ventricular lateral wall or apex. Two of these thrombi disappeared after anticoagulant therapy, one of which after hemiplegia. 2D echo is a useful tool for the diagnosis and surveillance of intraatrial or intraventricular thrombi. Intraatrial thrombi may be due to supraventricular arrhythmias in children; intraventricular thrombi are usually seen in association with poor left ventricular contractility. The diagnosis of thrombosis should lead to institution of anticoagulant or even fibrinolytic therapy in order to avoid systemic embolism.     

An Updated Review of the Efficacy and Safety of Direct Oral Anticoagulants in Treatment of Left Ventricular Thrombus

Left ventricular (LV) thrombus is a potentially serious complication affecting males and females with ischemic and nonischemic cardiomyopathy—specifically, after acute myocardial infarctions of the anterior left ventricular wall and long-standing tachyarrhythmias, respectively. LV thrombi pose significant risks for systemic embolization and devastating stroke events, while also demanding a treatment carrying inherent risks of its own. It is therefore imperative to have accurate detection of these ventricular thrombi and an appropriate understanding of the risks and benefits regarding management. Anticoagulation using warfarin has long been established as the gold-standard level of care in the current guidelines of the American College of Cardiology but the advent of direct oral anticoagulants (DOACs) prompts a re-examination of the literature. The particular question we seek to answer lies in the efficacy of these drugs and the safety and outcomes when used to treat LV thrombi. Recent case reports, meta-analyses, and most recently, the breakthrough of 2 novel randomized controlled trials have shown DOACs to be a promising treatment for LV thrombus. Contrarily, some retrospective cohort reviews suggest less-than-promising outcomes. This meta-analysis hopes to provide a current, curated review of up-to-date safety and efficacy in the documented tales of DOACs and LV thrombi that has been published since early 2020—by selecting these curated case studies, and analyzing the most recent randomized controlled trials, we hope to engage the reader with clearer illustrations of the key components of both the advocacy and warning of this pharmaceutical intervention.     

Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction

STUDY OBJECTIVES: To determine the frequency of left ventricular (LV) thrombi by echocardiography and to define the predictors of LV thrombus and subsequent thromboembolism. DESIGN: Retrospective case-control design. SETTING: Single tertiary care center. PATIENTS: Twenty-eight patients with LV thrombus in a consecutive series of 144 patients with severe LV dysfunction and follow-up period for a mean of 27.6 months. Measurements and results: Thirty-five clinical and echocardiographic variables were evaluated. The mean age of patients with (n = 28) vs patients without (n = 116) LV thrombus was 50.3 +/- 11.0 years vs 54.2 +/- 11.1 years (p = 0.09), with 22 patients (78.6%) and 78 patients (67.2%) being male (p = 0.24), respectively. The mean ejection fraction (EF) for those with vs those without LV thrombus was 17.5 +/- 5.5 vs 20.0 +/- 6.9 (p = 0. 08), with 16 patients (57.1%) and 42 patients (36.2%) having an EF < 20% (p = 0.04), respectively. The groups were similar with respect to other baseline characteristics, comorbid illnesses, and drug therapies other than anticoagulants. All 28 patients with LV thrombus (100%) and 54 of those without LV thrombus (46.6%) were treated with warfarin. Ischemic etiology of the cardiomyopathy (odds ratio, 4.78; 95% confidence interval, 1.51 to 15.11; p = 0.008) and increased LV internal diastolic dimension (LVIDD; odds ratio, 1.10; 95% confidence interval, 1.03 to 1.18; p = 0.004) were found to be independent predictors of thrombus formation. Peripheral embolism occurred in 5 patients (17.9%) vs 13 patients (11.2%) of those with and without LV thrombi, respectively (p = 0.35). Ischemic etiology of the cardiomyopathy (odds ratio, 3.79; 95% confidence interval, 1. 13 to 12.64; p = 0.03) and EF (odds ratio, 0.91; 95% confidence interval, 0.82 to 1.00; p = 0.04) were found to be independent predictors of systemic embolization. The patients with an embolic event suffered a significantly higher mortality (7 of 18 patients; 38.9%) during the follow-up period when compared to those without an embolic event (13 of 126 patients; 10.3%; p < 0.0001). CONCLUSIONS: We conclude that ischemic cardiomyopathy and dilated LV chamber sizes (LVIDD > 60 mm) are independently associated with LV thrombi. A peripheral embolic event is related to poor long-term survival in this patient group.     

Association between serum C-reactive protein elevation and left ventricular thrombus formation after first anterior myocardial infarction

STUDY OBJECTIVES: Most left ventricular (LV) thrombi that occur after acute myocardial infarction (AMI) are formed within 2 weeks, when inflammatory cells have infiltrated into the necrotic myocardium. Inflammatory changes on the endocardial surface may induce platelet deposition and fibrin net formation through interaction with proinflammatory cytokines. We sought to determine the significance of the inflammatory response reflected by serum C-reactive protein (CRP) elevation in LV thrombus formation after AMI. DESIGN: We examined 160 patients with first anterior AMI. Peak serum creatine kinase (CK) and CRP levels were determined by serial measurements. Echocardiography was performed 10 to 14 days after the onset. We assessed the association between the elevation of serum CRP levels and LV thrombus formation after AMI. RESULTS: LV thrombus was observed in 13 patients (8%). There was no difference in age, sex, coronary risk factors, preinfarction angina, use of revascularization therapy and anticoagulant therapy, platelet count, and fibrinogen level on hospital admission between the two groups. The mean (+/- SD) peak serum CRP level was markedly increased in patients with LV thrombus compared to those without (18.0 +/- 12.6 vs 9.4 +/- 8.1 mg/dL; p = 0.001), despite their having similar peak CK levels. Multivariate analysis showed that a peak CRP level of > or =20 mg/dL was an independent predictor of thrombus formation (relative risk, 4.82; p = 0.037) among variables including older age (> or =60 years old), peak CK level (> or =3,000 IU/L), and peak WBC count (> or =12,000 cells/ microL). CONCLUSION: A greater elevation of serum CRP level was associated with a higher incidence of LV thrombus after AMI, suggesting an important role of the inflammatory response in mural thrombus formation.     

Unusual thrombi in the setting of rheumatic heart disease

We report two patients with unusual intracavitary thrombi in association with rheumatic mitral stenosis. One patient had a large free-floating left atrial thrombus immediately after successful closed mitral valvotomy causing recurrent acute pulmonary oedema in the post-operative phase. The other patient was detected to have multiple, discrete and calcified left ventricular thrombi in the presence of severe left ventricular systolic dysfunction. The diagnosis in both cases was made by cross-sectional echocardiography.     

Peripheral emboli from left ventricular thrombi of different echocardiographic appearance in acute myocardial infarction

In four patients with anterior wall acute myocardial infarction (AMI) and left ventricular thrombi diagnosed by two-dimensional (2-D) echocardiography, disappearance of left ventricular thrombi was demonstrated by 2-D echocardiography immediately after the patients had suffered peripheral emboli. Two thrombi were pendulous with free motion during the cardiac contractions; one of these consisted of two separated pendulous clots that disappeared after two episodes of embolization six and 16 days, respectively, after the onset of AMI. Two thrombi were initially broad based, flat, and without intracavitary motion. One thrombus caused two episodes of peripheral emboli; the other began as a flat thrombus without intracavitary motion but progressed to show central echolucency and, then, vigorous intracavitary motion of the margin prior to embolization. Five of six embolic episodes occurred when these patients were receiving high-dose anticoagulants. These anticoagulants were administered once the thrombi were diagnosed. Left ventricular thrombi of very different appearance on 2-D echocardiography may cause embolization, which may occur during therapeutic anticoagulation administered after thrombi have developed in patients with AMI.     

High incidence of left ventricular thrombosis and systemic embolism in patients with left ventricular assist system]

The purpose of this study was to determine the incidence of left ventricular (LV) thrombosis and systemic embolism in 14 patients with LV assist systems. Echocardiography was used to detect LV wall motion abnormalities, intracavitary smoke-like echoes and thrombosis, and the effect of anticoagulant therapy was serially examined. During full assist of the circulation, the aortic valve did not open in any patient. Smoke-like echoes were observed in 9 patients (64%) and thrombi in 8 (57%). The thrombus developed within the first 3 assist days. Systemic anticoagulant therapy decreased the thrombus size in only 3 patients, but there was a possibility of intracranial or mediastinal bleeding in other 3 patients. Systemic embolism was noted in 7 of 11 autopsy patients (64%). The characteristic finding was that there were multiple embolized organs, such as the brain, kidneys, spleen and liver, in all patients. Development of a thrombus is a serious complication in all patients with LV assist systems. However, the problem does not lie in the assist system but in the left ventricle of the patient's own heart. It is also noteworthy that systemic anticoagulation is not effective for an LV thrombus. A new method of assisting the failing heart, or a new anticoagulant delivery technique for the LV cavity to prevent LV thrombus development is needed.     

Long-term prospective assessment of left ventricular thrombus in anterior wall acute myocardial infarction and implications for a rational approach to embolic risk

To prospectively assess the predictive value of left ventricular (LV) thrombus anatomy for defining the embolic risk after acute myocardial infarction (AMI), 2 comparable groups of patients with a first anterior AMI (group A, 97 thrombolysed patients; group B, 125 patients untreated with antithrombotic drugs [total 222]) underwent prospective serial echocardiography (follow-up 39 +/- 13 months) at different time periods. LV thrombi were detected in 26 patients in group A (27%) and in 71 in group B (57%; p <0.005). Embolism occurred in 12 patients (5.4%; 1 in group A [1%] vs 11% in group B [9%], p < 0.04). At multivariate analysis, thrombus morphologic changes were the most powerful predictor of embolism (p <0.001), followed by protruding shape (p <0.01) and mobility (p <0.02). In patients untreated with thrombolysis, a higher occurrence of thrombus morphologic changes (48% vs 8%, p <0.002) and protruding shape (69% vs 31%, p <0.002) were observed, whereas thrombus mobility was similar in the 2 groups (18% vs 8%, p = NS). Thrombus resolution occurred more frequently in thrombolysed patients (85% vs 56%, p <0.002). Thus, after anterior AMI, changes in LV thrombus anatomy frequently occur and appear the most powerful predictor of embolization. A minor prevalence of thrombus, a more favorable thrombus anatomy, and a higher resolution rate may contribute to reduce embolic risk after thrombolysis.     

Long term follow up of patients with anterior myocardial infarction complicated by left ventricular thrombus in the thrombolytic era.

OBJECTIVES: To examine the appearance and resolution of left ventricular thrombi and to study the relation between thrombus and mortality during long term follow up after anterior myocardial infarction. DESIGN: Ninety nine consecutive patients were prospectively studied until the last included patient had been followed for one year. Streptokinase and aspirin were used routinely, anticoagulants only after a decision by the attending physician. Echocardiography was performed within 3 d of admission, before discharge, and after one, three, and 12 months. SETTING: Umeå University Hospital, a teaching hospital in Northern Sweden. MAIN OUTCOME MEASURES: Left ventricular thrombus, segmental myocardial function, and mortality during follow up. RESULTS: Thirty patients (30%) had a thrombus on discharge. One month, three months, and 12 months after hospital discharge, the thrombus had resolved in 81%, 84%, and 90% of the patients, respectively. The proportion of resolved thrombi at one month was high irrespective of whether anticoagulants were given (10/11, 91%) or not (12/16, 75%), P = 0.4. New thrombi appeared in 12 patients after discharge and resolution and reapperance of thrombi continued during the follow up period. Patients who developed a thrombus during the hospital stay (n = 44, 44%) had more extensive myocardial dysfunction on discharge (P < 0.001) and significantly higher mortality during the follow up period than those without a thrombus (23% v 7%, P < 0.01). CONCLUSIONS: With routine thrombolytic and aspirin treatment of anterior myocardial infarction, left ventricular thrombi usually resolve during the first month after hospital discharge. Appearance and resolution of thrombi continue, however, in a significant proportion of the patients during long term follow up. A left ventricular thrombus during the initial hospital stay is associated with high long term mortality.