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Master Thesis

Étude de l'efficacité et de la sécurité des traitements anticoagulants chez les patients porteurs d'un thrombus intraventriculaire gauche

Abstract : Background: Direct Oral Anticoagulants (DOA) are used in clinical practice for the treatment of left ventricular thrombus (LVT), despite the lack of scientific evidence of their efficacy and safety in this indication. The aim of this study was to describe the effect of anticoagulation therapy (vitamin K antagonists (VKA) or DAO) on LVT; and second, to identify predictors of LVT regression and clinical outcomes. Methods: from january 2012 to december 2020, all adult patients with a diagnosis of LVT and at least a 4 months follow-up were retrospectively included. The type of anticoagulant and antithrombotic treatment was collected, as well as the evolution of the thrombus. Biological, ultrasound and clinical data were collected, as well as Major Cardiac and Cerebrovascular Events (MACCE), which included death, stroke or transient ischemic attack, myocardial infarction, peripheral arterial embolism and major bleeding. Results: 90 patients were eligible. 3 patients were excluded due to exclusive heparin treatment. The population was young (mean age 62±11 years), mostly men (82%), with 78% ischemic cardiomyopathies, largely severe (LVEF 35% on average). 77% of patients were treated with VKA and 23% with DOA. 80% of patients received at least one antiplatelet therapy in combination. 80.2% of LVT disappeared completely, with no significant difference between the VKA and DOA groups. LVT reappeared in 8 patients (2 on VKA, 6 off treatment). The factors associated with a non-disappearance of LVT were a plan LVT (52.9% vs 23.2%; p=0.02), a low LVEF (29.5%±8.6 vs 36%±10, 3; p=0.0194) and a calcified thrombus (41.2% vs 0%; p<0.0001). The non-disappearance of LVT was significantly associated with more embolism (11.8% vs. 0% p=0.0372), and major bleeding (23.5% vs. 4.4%, p=0.0261). During a median follow-up of 30 (10.5-58.5) months, there were 15 MACCE, i.e. 17.2% of our patients, with 24 events: 14% deaths from all causes (including 9,5% of cardiovascular deaths), 3.5% stroke/TIA, 2.3% embolism, 8.1% major bleeding. There was no significant difference in the occurrence of MACCE between the DOA and VKA groups (15.0% and 17.9% respectively, p=1), but the MACCE were significantly associated with an older age ( 70.7 years vs. 60.3 years; p=0.001), impaired renal function (estimated GFR 54.2 vs. 75.5 ml/min/1.72m2; p=0.007), and presence of a left ventricular aneurysm (46.7% versus 19.4%; p=0.0427). There was a tendency for more deaths from all causes in the VKA group (18.2% versus 0%, p=0.0604). Conclusion: in our study, VKA and DOA anticoagulant treatments appear to be similarly effective in resolving TIVG (80%), which is significantly associated with a decrease in embolic risk and hemorrhagic risk. The presence of LVT is associated with a high risk of MACCE (17% of our patients), with no significant difference between the VKA and DOA groups. There was a nonsignificant trend for a higher death rate in the VKA group. There was no difference between the characteristics of the patients between the two groups, which shows that there was no particular patient profile for which the practitioner favored DOAC. However, routine prescription of DOACs for the treatment and prevention of recurrence of LVT requires more morbidity and mortality data, which the prospective studies in progress may provide soon.
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Master Thesis
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Caroline Beaufrere. Étude de l'efficacité et de la sécurité des traitements anticoagulants chez les patients porteurs d'un thrombus intraventriculaire gauche. Médecine humaine et pathologie. 2020. ⟨dumas-03155431⟩

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