The optimal management of left ventricular thrombus (LVT) is unknown, particularly with the emergence of the non-vitamin K antagonist anticoagulants (NOACs).

To identify the independent correlates of LVT regression and clinical outcomes.

A computerized case sensitive search on 90 065 consecutive echocardiograms performed between January 2011 and December 2017 identified patients with a LVT. Repeated echocardiographic data, treatment and major adverse cardiac events (MACE), including death, stroke, myocardial infarction or acute peripheral artery emboli were analyzed as well as major bleeding events (BARC ≥3) and all-cause mortality.

We included 159 patients with an LVT confirmed by two independent experts. Patients were treated by vitamin K antagonists (48.4%), parenteral heparins (27.7%) and NOACs (22.6%) with additional antiplatelet therapy in 67.9% of the population. Total LVT regression was reached in 62.3% of the patients in a median time of 103 [32–392] days. The independent correlates associated with LVT regression were a non-ischemic cardiomyopathy (HR 0.36; 95%CI [0.19–0.69], P=0.002) and a smaller baseline thrombus area (HR 0.66; 95%CI [0.45–0.96], P=0.031). Cardiovascular events were frequent with 37.1% of MACE, 18.9% of major bleeding and 13.2% of all-cause mortality during a median follow-up of 632 [187–1126] days. A left ventricular ejection fraction >35% (HR 0.46; 95%CI [0.23–0.93], P=0.029) and an anticoagulation therapy>3 months (HR 0.42; 95%CI [0.20–0.88], P=0.021) were independently associated with less MACE. A reduced risk of mortality was observed among patients that obtained a total LVT regression (HR 0.48; 95%CI [0.23–0.98]; P=0.039) (Fig. 1).

The presence of LVT was associated with a very high risk of MACE and mortality. Total thrombus regression, obtained with either vitamin K antagonists or NOACs, led to a better prognosis.