Left ventricle pedunculated thrombi risks and outcomes: a case report and literature review

Q: What is the clinical evidence from this study?

Study design: Systematic Review. Population: Pedunculated left ventricular thrombi (n=57). Intervention: Surgical removal vs anticoagulation therapy vs. Oral and intravenous anticoagulation (warfarin or heparin). Primary outcome: Distal embolization and treatment success/mortality.

Q: What does this research mean for the field?

Surgical removal is highly effective and definitive for pedunculated left ventricular thrombi, whereas medical anticoagulation carries a substantial failure rate. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Ahmed Ali Ali; Eman Elsayed Sakr

doi:10.1590/1677-5449.202301242

January 1, 2024Jornal Vascular BrasileiroOpen Access

Left ventricle pedunculated thrombi risks and outcomes: a case report and literature review

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Key result

Surgical removal was the definitive treatment in 75.4% (43/57) of pedunculated LV thrombus cases and was almost always successful, whereas anticoagulation had a 41.6% (5/12) failure rate.

Figures

Key Points

To evaluate the clinical features, embolic risks, and therapeutic outcomes of pedunculated left ventricular thrombi.
Reported an index case of a 42-year-old male with ischemic cardiomyopathy and fatal pedunculated left ventricular thrombi following bilateral femoral artery embolization.
Systematically searched PubMed and Scopus databases, analyzing 56 published cases alongside the index case for a total cohort of 57 patients.
Definitive surgical excision was performed in 75.4% (N=43) of cases, whereas anticoagulation had a 41.6% (5/12) failure rate and accounted for all three patient deaths.

Study Design

Type

Systematic Review (n=57)

Structured PICO

P

Population

57 cases of pedunculated left ventricular thrombi at initial assessment (56 from a systematic literature review plus 1 index case of a 42-year-old man with ischemic cardiomyopathy), mean age 50.5 years, 66.6% male.

E

Exposure

Surgical removal of LV thrombus (performed in 75.4% [43/57] of reviewed cases) or anticoagulation/thrombolytic therapy (in the index case: bilateral femoral mechanical thrombectomy and fasciotomy followed by warfarin 5 mg once daily and enoxaparin sodium 100 mg twice daily; in reviewed cases: warfarin, heparin infusion, tirofiban, recombinant tissue plasminogen activator, or streptokinase).

O

Outcome

Treatment success, distal embolization, and mortalityhard clinical

Pedunculated left ventricular thrombi carry a high risk of distal embolization (57.8%) and anticoagulation failure (41.6%), supporting early surgical removal and multidisciplinary management as the preferred strategy.

Limitations

Delayed access to transthoracic echocardiography in the index case (performed only after the operation), preventing early diagnosis and multidisciplinary management
Absence of histopathological confirmation in the index case
Absence of histopathological confirmation of the LV thrombus in the presented case
Delayed access to transthoracic echocardiography (TTE), which was only performed after the vascular operation
Delayed diagnosis prevented early multidisciplinary management and early discussion between vascular and cardiothoracic teams

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Implication

Supports early surgical removal for pedunculated LV thrombi; extends systematic review evidence toward multidisciplinary guidelines.

Abstract

A 42-year-old male with ischemic cardiomyopathy presented with acute bilateral femoral artery embolization. After management with embolectomy and fasciotomy in both femoral arteries, transthoracic echocardiography revealed two pedunculated highly mobile left ventricle (LV) thrombi. Given the procedural risk, anticoagulation therapy was recommended over surgery. However, the bleeding risk impeded the continuation of anticoagulation, which increased the thrombus size. Multiorgan failure and disseminated intravascular coagulopathy followed and the patient died. We also systematically reviewed the PubMed and Scopus databases for pedunculated LV thrombi cases and retrieved 74 and 63 reports respectively. Of these, 37 relevant reports (45 cases) plus 11 reports from the manual search were included for data extraction, a total of 56 cases besides our case. Based on the etiologies and risks, LV thrombi are predictable and preventable, especially after ischemic events. A clear diagnostic algorithm and vigilant follow-up are needed as well as multidisciplinary management once a diagnosis is confirmed.

Discussion

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Cite This Study

Ali et al. (2024) conducted a systematic review in Pedunculated left ventricular thrombi (n=57). Surgical removal vs anticoagulation therapy vs. Oral and intravenous anticoagulation (warfarin or heparin) was evaluated on Distal embolization and treatment success/mortality. Surgical removal was the definitive treatment in 75.4% (43/57) of pedunculated LV thrombus cases and was almost always successful, whereas anticoagulation had a 41.6% (5/12) failure rate.

synapsesocial.com/papers/6a804b1265e62327953d3801 https://doi.org/10.1590/1677-5449.202301242

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Left ventricle pedunculated thrombi risks and outcomes: a case report and literature review

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Left ventricle pedunculated thrombi risks and outcomes: a case report and literature review

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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