Introduction

Left ventricular thrombus (LVT) remains a clinically important complication associated with substantial thromboembolic morbidity despite advances in reperfusion therapy and contemporary heart failure management [1-5]. LVT typically develops in the setting of left ventricular systolic dysfunction, regional wall-motion abnormalities, and intracavitary blood stasis, most commonly following large anterior ST-segment elevation myocardial infarction (STEMI), although increasing recognition in nonischemic cardiomyopathies has broadened its clinical significance [1,4,6-9].

Current American College of Cardiology and American Heart Association recommendations support anticoagulation for approximately three months with repeat imaging to confirm thrombus resolution [8-11]. However, important uncertainties remain regarding the optimal duration of therapy, particularly in patients with persistent ventricular dysfunction, recurrent thrombus formation, or thrombus development unrelated to acute myocardial infarction [8-18]. Existing literature demonstrates that recurrence of LVT and thromboembolic events may occur even after apparent thrombus resolution and discontinuation of anticoagulation [19]. Some studies suggest that embolic risk persists beyond six months, raising questions regarding whether selected patients may benefit from prolonged or individualized anticoagulation strategies [20]. Although contemporary studies support the use of direct oral anticoagulants (DOACs) as alternatives to vitamin K antagonists (VKAs) [12-20], current treatment decisions largely remain based on generalized recommendations rather than patient-specific risk assessment. Emerging evidence suggests that thrombus morphology, imaging characteristics, clinical variables, artificial intelligence (AI)-assisted image analysis, and genomic risk factors may identify patient subgroups at increased risk for persistence, recurrence, and thromboembolic complications [17].

Although contemporary guidelines recommend anticoagulation followed by interval imaging, important uncertainties remain regarding management of patients who develop LVT despite prescribed anticoagulation, particularly in the setting of chronic left ventricular dysfunction unrelated to acute myocardial infarction. Medication adherence, thrombus morphology, and persistent ventricular remodeling may substantially influence recurrence risk and optimal treatment duration.

We present a case of incidentally identified LVT in a patient with ischemic cardiomyopathy, chronic heart failure with reduced ejection fraction (HFrEF) diagnosed in 2022, atrial flutter status post flutter line ablation, and stage II chronic kidney disease who developed an apical thrombus still present after a few months of anticoagulation, with inconsistent medication adherence identified as a likely contributing factor. This case highlights evolving patterns of LVT outside the traditional post-ST-segment elevation myocardial infarction (STEMI) setting and underscores the need for individualized, risk-adapted management strategies that integrate clinical, imaging, and emerging precision medicine approaches.