Coronary Artery Disease
Incidence and Predictors of Early Left Ventricular Thrombus After ST-Elevation Myocardial Infarction in the Contemporary Era of Primary Percutaneous Coronary Intervention

https://doi.org/10.1016/j.amjcard.2013.12.015Get rights and content

The aim of this study was to define the incidence of left ventricular thrombus (LVT) and its predictors in the contemporary era of primary percutaneous intervention (pPCI) and contrast echocardiography. We retrospectively analyzed 1,059 patients presenting with ST-elevation myocardial infarction (STEMI) to our tertiary cardiac center and treated with pPCI. Preprocedural pharmacology and procedural technique (including access route, the use of drug-eluting stents, and thrombectomy) were at the operators' discretion. Transthoracic echocardiography was performed before discharge; echo contrast agent was used when appropriate. LVT was detected in 42 subjects (4%). There were no significant differences in baseline demographics or pre-PCI clinical features between the 2 groups. Post-treatment, mean ejection fraction (EF) in patients with LVT was 35 ± 8.4% and in those without LVT was 47 ± 10%, p <0.001. Thirty-seven patients (88%) in the LVT group presented with an anterior STEMI versus 471 patients (42%) in the without LVT group (p <0.001). Apical akinesis was noted in all patients with LVT irrespective of the principal location of the MI. Multivariate analysis predictors of LVT were reduced EF, anterior site of MI, and the use of platelet glycoprotein IIb/IIIa inhibitors. After diagnosis of LVT, patients were treated with warfarin for 3 to 6 months. No significant difference in mortality was detectable at discharge between the 2 groups. In conclusion, in the contemporary era of pPCI, the incidence of LVT in patients with STEMI is significantly lower than that of the previous (thrombolysis) literature. The early presence of LVT is more likely in patients with anterior STEMI (involving the apex) and reduced EF.

Section snippets

Methods

We retrospectively analyzed 1,059 patients urgently transferred for pPCI to Kings College Hospital with a diagnosis of STEMI. Kings College Hospital is a tertiary referral center with a busy and mature (>10 years), 24 hours, 7 days per week pPCI service. Patients were included when they fulfilled the diagnostic criteria for STEMI: characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic ST elevation and subsequent release of biomarkers of myocardial

Results

A total of 1,059 subjects with STEMI underwent pPCI at Kings College Hospital in the study period. Patients were enroled from January 1, 2009 to August 31, 2012. The data were analyzed retrospectively. The mean age of the total population was 62 ± 13 years, and 26% of the patients were women.

All patients underwent 2-dimensional TTE. LVT was confidently confirmed in 25 cases (2%) and excluded in 885 cases (84%), and in the remaining 149 patients (14%), a contrast study was performed to clarify

Discussion

In this large cohort of patients presenting with STEMI treated with pPCI, the incidence of LVT is significantly reduced (4%) compared with data from the pre-PCI era. This may be due to an early and aggressive reperfusion strategy and to the use of modern contrast echo technology to improve the diagnosis of LVT and eliminate false positives. Predictors of LVT comprise reduced EF, anterior location of MI, and the use of GP IIb/IIIa inhibitors.

In the context of STEMI, prolonged ischemia results in

Disclosures

The authors have no conflicts of interest to disclose.

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