Prognostic value of left ventricular global longitudinal strain for adverse outcomes in patients with left ventricular thrombus and preserved left ventricular ejection fraction

Background Left ventricular thrombus (LVT) is associated with high thromboembolic and mortality risk, and is typically diagnosed post-myocardial infarction or in patients with reduced left ventricular ejection fraction (LVEF). The clinical trajectory of LVT patients with preserved LVEF is less well-studied, hence our study aimed to characterise this cohort of patients and to evaluate the prognostic significance of left ventricular global longitudinal strain (LVGLS), a marker of subclinical systolic dysfunction not captured by LVEF. Methods This was a retrospective cohort study of 135 patients with transthoracic echocardiographically (TTE) confirmed LVT and LVEF ≥40% at a tertiary centre between 2011 and 2021. Patients were stratified by LVGLS on initial TTE into abnormal (less negative than -16%; n=108) and normal (more negative than -16%; n=27) groups for analysis. The primary endpoint was a composite outcome including stroke/transient ischaemic attack, acute myocardial infarction, acute decompensated heart failure, and all-cause mortality on follow-up. Results Among 135 LVT patients with preserved ejection fraction (mean age 58.4 ± 13.9 years, 83.0% male), 20.0% (n = 27) had abnormal LVGLS of less negative than -16%. Baseline demographics, co-morbidities, LVT aetiology and characteristics on TTE, and medical therapy including anticoagulation were similar across both groups. Patients with abnormal LVGLS had lower initial LVEF (44.7 ± 5.4% vs. 49.3 ± 8.7%, p <0.001), and encountered higher incidence of composite outcome (47.2% [n = 56] vs. 18.5% [n = 5], p = 0.007). Kaplan-Meier analysis demonstrated significantly lower event-free survival for composite outcome in the abnormal LVGLS group (log-rank p=0.021). On Cox proportional hazards regression model, less negative LVGLS (per %) was independently associated with higher hazard of composite outcome (aHR 1.10, 95% CI 1.01 – 1.21, p = 0.033) after adjusting for age, sex, ischaemic heart disease, haemoglobin, and estimated glomerular filtration rate, across a mean follow-up duration of 5.2 ± 3.4 years. LVGLS was not associated with all-cause mortality or LVT resolution. Conclusion Abnormal LVGLS was associated with higher risk of adverse cardiovascular events in LVT patients with LVEF ≥40%, and provided incremental prognostic information beyond LVEF, aiding risk stratification.