The Dilemma in the Management of Patients with Heart Failure with Reduced Ejection Fraction, Sinus Rhythm and Left Ventricular Spontaneous Echo Contrast: A Narrative Review

Heart failure (HF) is a complex clinical syndrome that arises from structural or functionalimpairment of ventricular filling or ejection of blood, resulting in previous characteristicsymptoms of fatigue, dyspnea, and fluid retention. Among the complications of heart failure isthe development of spontaneous echo contrast (SEC), characterized by a smoke-resembling appearanceon echocardiograms, which indicates blood stasis in heart chambers. Despite beingidentified as an echocardiographic marker in the left atrium that correlates with thrombus formationand causes thromboembolic events, the clinical importance of left ventricular spontaneousecho contrast (LV-SEC) and the appropriate management for patients with this conditionremain uncertain due to insufficient data. Anticoagulant therapy is generally recommended forpatients with established left ventricular thrombus (LVT). However, for patients with heart failurewith reduced ejection fraction (HFrEF) and sinus rhythm (SR), as a result of a decrease inthromboembolic events over time, it is typically not recommended. The main challenge lies inassessing the thromboembolic risk and determining appropriate management in patients withHFrEF, sinus rhythm (SR), and left ventricular spontaneous echo contrast (LV-SEC), comparedto those with left ventricular thrombus (LVT) and those with HFrEF and SR without LV-SEC.The aim of this paper is to review the guidelines and trials on clinical characteristics, outcomes,and management of patients with LV-SEC and compare the suggested management with the establishedmanagement for LVT and HF patients with sinus rhythm without LV-SEC.