**1. Introduction**

A left ventricular (LV) thrombus is a known complication following acute myocardial infarction (AMI) that can lead to systemic thromboembolism. With the increasing use of timely thrombolysis and primary percutaneous interventions (PCIs), along with the unabated use of secondary prevention medications, the complications following AMI are decreasing and survival is improving [1]. After myocardial infarction (MI), LV thrombus still remains as high as 15% in the PCI era [2,3]. An LV thrombus usually occurs within 1 month post ST elevation MI, mostly occurs in the setting of acute anterior wall MI, and is associated with poor outcomes. The consideration of optimal anticoagulation, along with the decision of revascularization, makes decision-making a challenge. Echocardiography is the standard screening tool for detecting a thrombus, but sometimes contrast echocardiography might be required for confirming the diagnosis. The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the management of AMI recommend oral anticoagulants (OAC) in addition to dual antiplatelet (DAPT) agents for the treatment and prevention of LV thrombi in acute MI [4]. However, the use of triple therapy comes at the cost of increased bleeding complications [5]. Bleeding following

**Citation:** Pradhan, A.; Bhandari, M.; Vishwakarma, P.; Salimei, C.; Iellamo, F.; Sethi, R.; Perrone, M.A. Anticoagulation for Left Ventricle Thrombus—Case Series and Literature Review for Use of Direct Oral Anticoagulants. *J. Cardiovasc. Dev. Dis.* **2023**, *10*, 41. https:// doi.org/10.3390/jcdd10020041

Academic Editors: Giovanni Cimmino and Plinio Cirillo

Received: 3 December 2022 Revised: 18 January 2023 Accepted: 19 January 2023 Published: 23 January 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

anticoagulation is also associated with an increase in mortality. Hence, balancing the ischemic benefits against bleeding events is a common clinical dilemma. The introduction of direct oral anticoagulants (DOACs) has revolutionized the scenario of the anticoagulation of vascular thromboembolism, including atrial fibrillation (AF). Studies conducted to assess the efficacy of dual therapy (single antiplatelet with OAC) in patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) undergoing PCI have shown encouraging results with respect to attenuated bleeding and preserved efficacy. Additionally, DOACs have been found to be comparable with vitamin K antagonists (VKAs) [6–9]. Although these studies did not involve patients with an LV thrombus per se, a large body of affirmative data in the form of case reports, case series, observational studies and small randomized studies has emerged regarding the safety and efficacy of DOACs in treating LV thrombus. In this case series, we try to address this fairly common yet underestimated and underrepresented situation.

#### **2. Case Summary**

#### *2.1. Case 1*

A 46-year-old man with conventional cardiovascular risk factors presented with complaints of severe sudden onset chest pain of a 4-day duration. On examination, he had a dyskinetic apex with an LV third heart sound. His electrocardiogram was suggestive of anterior wall ST elevation MI, and his echocardiography showed a 1.8 cm × 1.5 cm clot at the apex (Figure 1a) and attendant severe LV dysfunction. The patient underwent coronary angiography, which revealed the 95% stenosis of the proximal left anterior descending artery with poor contractility of LV. In view of his severe LV dysfunction, late presentation, and pain-free status, he was subjected to myocardial perfusion imaging. Anticoagulation with VKA was initiated and was targeted to an INR 2.0–3.0. DOACs were not used, because the patient refused owing to financial constraints. Stress imaging (Technetium-99 single-photon emission computerized tomography) did not reveal any evidence of viability, and dual therapy was continued for 1 month. The LV thrombus resolved by the end of 1 month, but we still continued dual therapy (clopidogrel and oral warfarin), along with optimal medical treatment. He is planned for repeat echocardiography after 3 months and is under follow-up.

**Figure 1.** Echocardiographic demonstration of thrombus in two cases managed by different anticoagulation regimens. (**1a**)—two-dimensional echocardiography in apical view showing homogenous echo dense mass (1.8 × 1.5 cm) at apex of left ventricle, suggestive of thrombus. (**1b**)—two-dimensional echocardiography in apical view showing large echo dense mass (5.4 × 7.1 cm) at apex of a dilated and akinetic left ventricle, suggestive of thrombus.
