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 functional impairment of ventricular filling or ejection of blood, resulting in previous characteristic symptoms of fatigue, dyspnea, and fluid retention. Among the complications of heart failure is the development of spontaneous echo contrast (SEC), characterized by a smoke-resembling appearance on echocardiograms, which indicates blood stasis in heart chambers. Despite being identified as an echocardiographic marker in the left atrium that correlates with thrombus formation and causes thromboembolic events, the clinical importance of left ventricular spontaneous echo contrast (LV-SEC) and the appropriate management for patients with this condition remain uncertain due to insufficient data. Anticoagulant therapy is generally recommended for patients with established left ventricular thrombus (LVT). However, for patients with heart failure with reduced ejection fraction (HFrEF) and sinus rhythm (SR), as a result of a decrease in thromboembolic events over time, it is typically not recommended. The main challenge lies in assessing the thromboembolic risk and determining appropriate management in patients with HFrEF, sinus rhythm (SR), and left ventricular spontaneous echo contrast (LV-SEC), compared to 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 established management for LVT and HF patients with sinus rhythm without LV-SEC.