Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Treatment of Left Ventricular Thrombi—Insights from a Swiss Multicenter Registry - 05/04/23

Doi : 10.1016/j.amjcard.2023.01.018

Thomas Seiler, MD ^a,^⁎, Egle Vasiliauskaite, MD ^a,^⁎, Daniel Grüter, MD ^a,^b, Mabelle Young, MD ^a, Adrian Attinger-Toller, MD ^a, Mehdi Madanchi, MD ^a, Giacomo Maria Cioffi, MD ^a, Gregorio Tersalvi, MD ^a, Gina Müller, BSc ^a, Simon F. Stämpfli, MD ^a,^c, Bart de Boeck, MD, PhD ^a, Yves Suter, MD ^b, Jörg Nossen, MD ^d, Stefan Toggweiler, MD ^a, Walter A. Wuillemin, MD, PhD ^e, Florim Cuculi, MD ^a,^f, Richard Kobza, MD ^a, Matthias Bossard, MD ^a,^f,^⁎
^a Cardiology Division, Heart Center - Luzerner Kantonsspital, Luzern, Switzerland
^b Department of Internal Medicine, Luzerner Kantonsspital, Wolhusen, Switzerland
^c Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
^d Department of Internal Medicine, Luzerner Kantonsspital, Sursee, Switzerland
^e Hematology Division, Luzerner Kantonsspital, Luzern, Switzerland
^f Faculty of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland

^⁎Corresponding author: Tel: +41 41 205 14 77.

Résumé

Current guidelines recommend vitamin K antagonists (VKAs) for the treatment of a left ventricular thrombus (LVT). However, direct oral anticoagulants (DOACs) show superior safety and efficacy compared with VKAs in most thromboembolic disorders. Nevertheless, DOACs remain poorly investigated for the treatment of LVT. To describe the thrombus resolution rate and clinical efficacy of DOACs versus VKAs in patients with LVT, we analyzed consecutive patients with confirmed LVT from a multicenter echocardiography database. Echocardiograms and clinical end points were evaluated independently. The thrombus resolution rate and clinical outcomes were compared according to the underlying anticoagulation regimen. In total, 101 patients were included (17.8% women, mean age 63.3 ± 13.2 years), 50.5% had recently experienced a myocardial infarction. The mean left ventricular ejection fraction was 36.6 ± 12.2%. DOACs versus VKAs were used in 48 and 53 patients, respectively. The median follow-up was 26.6 (interquartile range 11.8;41.2) months. Among patients receiving VKAs compared with DOACs, the thrombus resolved more rapidly within the first month in those taking VKAs (p = 0.049). No differences were seen between the 2 groups with respect to major bleedings, strokes, and other thromboembolic events. In each group, LVT recurred in 3 of the subjects (a total of 6) after discontinuation of anticoagulation. In conclusion, DOACs appear to be a safe and effective alternative to VKAs for the treatment of LVTs, but the rate of thrombus dissolution within 1 month after initiation of anticoagulation appears to be higher with VKAs. A sufficiently powered randomized trial is required to definitively define the role of DOACs in the treatment of LVT.

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Plan

	Thomas Seiler and Egle Vasiliauskaite, contributed equally to this manuscript and share the first authorship.
	Richard Kobza and Matthias Bossard contributed equally to this manuscript and share the senior authorship.
	Funding: none.