Comparison of direct oral anticoagulants and vitamin K antagonists in the treatment of left ventricular thrombi: a retrospective cohort study

Hossam Elbenawi; Kirsten Lipps; Samuel Heller Jr; David A Liedl; Raymond C Shields; Ana I Casanegra; Stanislav Henkin; Thom W Rooke; Paul W Wennberg; Waldemar E Wysokinski; Robert D McBane; Damon E Houghton

doi:10.1016/j.rpth.2025.103192

Comparison of direct oral anticoagulants and vitamin K antagonists in the treatment of left ventricular thrombi: a retrospective cohort study

Res Pract Thromb Haemost. 2025 Sep 24;9(7):103192. doi: 10.1016/j.rpth.2025.103192. eCollection 2025 Oct.

Authors

Hossam Elbenawi^{1

2}, Kirsten Lipps¹, Samuel Heller Jr³, David A Liedl², Raymond C Shields^{1

2}, Ana I Casanegra^{1

2}, Stanislav Henkin^{1

2}, Thom W Rooke^{1

2}, Paul W Wennberg^{1

2}, Waldemar E Wysokinski^{1

2}, Robert D McBane^{1

2}, Damon E Houghton^{1

2

4}

Affiliations

¹ Division of Vascular Medicine, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
² Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA.
³ Second Faculty of Medicine, Charles University, Prague, Czech Republic.
⁴ Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Abstract

Background: Left ventricular thrombus (LVT) is a serious thromboembolic complication in patients with cardiomyopathies. Evidence supporting direct oral anticoagulant (DOAC) therapy in LVT is limited.

Objectives: We evaluated the effectiveness and safety of DOACs compared with vitamin K antagonists (VKAs) in patients with LVT.

Methods: A multisite retrospective cohort study was performed, including patients with LVT diagnosed by echocardiography from 2018-2023 who were treated with either DOACs or VKAs. Primary outcome was the incidence of stroke and systemic embolism (SSE). Secondary outcomes included LVT resolution, major bleeding, and all-cause mortality.

Results: A total of 182 patients with LVT met inclusion criteria, of which 70 (38.5%) were treated with only DOACs and 112 (61.5%) with only VKAs. The mean age was 66 years, and 74% of the patients were male. The median follow-up duration was 363.5 days (IQR, 139-950). No significant difference between the groups was observed in the incidence of SSE (DOAC, 5.7% vs VKA, 5.4%; P = 1.0), the incidence of LVT resolution (DOAC: 81.4% vs VKA: 87%; P = .35), the median time to LVT resolution (DOAC, 96 days vs VKA, 102 days; P = .22), or mortality (DOAC, 14.3% vs VKA, 11.6%; P = .6). However, VKAs were associated with a significantly higher incidence of major bleeding compared with DOACs (9% vs 1.4%; P = .02).

Conclusion: LVT treated solely with either DOACs or VKAs had similar incidences of SSE, LVT resolution, time to LVT resolution, and mortality. VKA therapy, however, was associated with a higher incidence of major bleeding events.

Keywords: direct oral anti-coagulant; left ventricular thrombus; stroke; systemic embolism; vitamin K antagonists.