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“ WAVE RED FLAG” FOR ANTICOAGULATION, WHEN YOU ENCOUNTER MOBILE LV CLOT !

Venkatesan Sangareddi , G. Gnanavelu ,M.A Rajasekar, V.Jaganathan

Department of cadiology , Madras medical college , Chennai.

Formation of LV mural thrombus is one of the important sequel of STEMI. The natural history of LV clot is variable. Spontaneous dissolution often occur . Stroke and peripheral embolism, are other natural events by which left ventricle get rid of the clot. The morphology and the behavior of LV clot is determined by endogenous procoagulant and fibrinolytic mechanisms. Drugs administered in the peri infarct phase also play an important role. In current thrombolytic era ,the incidence of LV clot has come down. Once the clot begins to form over the raw area adjoining a dyskinetic segment, it follows the local hemodynamic factors , that determine the shape , size of the clot which varies from linear , layered , projectile or pedunculated.

Administration of oral anticoagulants remain the standard practice in patients with LV clot. It is prescribed , in the hope that it will prevent the progression of clot and prevent thrombo embolism . Whether, long term warfarin dissolve , regress or dislodge the thrombus is not known. We have observed the incidence of CVA is high in the first few weeks following introduction of oral anticoagulants . We report our experience in 8 patients, with LV clot in Acute MI . All patients were male . Age range 22-58 .All had anterior MI. The mean EF was 38%(28-43%) the mean size of LV clot was 1.4cm (7mm -24mm) mobility was graded with reference to independent movement parallel or perpendicular to the LV. 3 had highly mobile clot. 5 had relatively fixed clot. All were put on titrated warfarin. Two patients who had large LV clot with a stalk got dislodged after starting anticoagulation. The CVA occurred on 12 th and 14 th day after starting warfarin .The pedicle is probably the vulnerable point and is exposed to greatest risk for dissolution . On the other hand the 5 patients who showed relatively stable clots are attending to our cardiology OPD without any events . One patient who had a mobile clot , which got organized at 4 weeks , incidentally this patient had discontinued anticoagulants.

We conclude, oral anticoagulation has a potential to destabilise and dislodge a mobile LV clot in the early days following STEMI .Existing anticoagulation protocol recommends, oral anticoagulation for all patients who have LV clot. This need to be redefined. If surgery is not an option , temporary withdrawal of anticoagulation may be indicated in selected patients with LV clot, to facilitate organization of clot.


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LV clot formation is one of the important complications of acute myocardial infarction. Preventing this is difficult and managing this problem is still more difficult.Some of these clots are linear and laminar along the shape of LV apex and carry less risk of dislodging.

 While mobile LV clots , even if it is small can cause a embolic episode. Most of these patients have a significant LV dysfunction and they are candidates for early CAG and revascularisation. Even If the coronary anatomy is very ideal for a PCI these patients are often sent for CABG and physical removal of LV clot . If  only ,we have an option to remove these LV clots by a catheter based modality, we can offer them a totally non surgical cure.

This is not impossible,  considering  we are in the era of percutaneous implantation of prosthetic valve in Aorta ! The only issue is potential embolism into carotids and periphery .A temporary distal protection at the level of aortic root will prevent that .

Device companies shall produce one such exclusive catheter system to remove LV clot.

Dr .S.Venkatesan, Madras medical college, Chennai,India

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