The spongy heart paradox: balancing bleeding and clotting risk in left ventricular noncompaction cardiomyopathy

Left ventricular noncompaction cardiomyopathy (LVNC) is an increasingly recognized cardiomyopathy with distinctive structural features and a disproportionate risk of systemic thromboembolism. The clinical dilemma of anticoagulation is pressing: while impaired systolic function and deep trabecular recesses predispose to thrombus formation, anticoagulation simultaneously increases bleeding risk, particularly in older patients with multiple comorbidities. Conventional risk scores such as CHA₂DS₂-VASc and HAS-BLED were derived from atrial fibrillation populations and remain unvalidated in LVNC, limiting their clinical applicability. Advanced imaging modalities, particularly cardiac magnetic resonance imaging (cMRI), provide incremental value by quantifying trabeculation, identifying thrombus, and characterizing fibrosis; however, their integration into risk algorithms is inconsistent. This review synthesizes available evidence, highlights the limitations of current approaches, and emphasizes the need for individualized, dynamic assessment of both thromboembolic and bleeding risks. Future priorities include the development of LVNC-specific risk prediction models, the establishment of prospective multicenter registries, and the incorporation of imaging and biomarker data into precision anticoagulation strategies to guide therapy in this rare but high-risk population.