In patients with post-MI LV thrombus which resolves after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?

I think the key word here is akinesis (or dyskinesis); effectively, an immobile segment of myocardium gravitationally farthest south of the ‘northward’ flow of blood across the aortic valve. This effectively allows for stasis in an injured and immobile region... two of the three components of Virchow’s triad.

While serial imaging is unnecessary (very similar to the lack of need for serial imaging of an LA appendage in chronic atrial fibrillation), lifelong AC with DOAC or VKA would be within the standard of care.

Recovery of apical wall motion to hypokinesis, however, may lower the threshold for AC cessation.

3-6 months of anticoagulation is enough for the recovery of any stunted myocardium at the apex and generation of new endothelium. I use DAPT after that phase if the repeat echo shows resolution of the clot. Another repeat echo with contrast in 3 later is done again.

In our large practice, we have seen cases of thrombus recurring, in which we resumed anticoagulant therapy for life.

I have a patient in their early 70s who had an anterior wall MI when he was in his late 30s. He had a large clot in the akinetic apex and was treated with anticoagulation for several years. The anticoagulation was stopped, and for many years, no clot was seen. On a routine echo a few months ago, he had a 2 cm thrombus at the apex, which appeared to be partly calcified. He was given Eliquis, and 3 months later, the entire mass was gone. Whether it dissolved or embolized is uncertain, but he had no clinical evidence of an embolization.

The teaching point to me is that a large area of akinesia produces a persistent risk of thrombus formation.

Yes. Theoretically, the risk for clot formation is highest immediately post MI. One can hope apical function improves over time. An anti-platelet regimen may also help prevent recurrence of thrombus formation.

Surveillance with Echo [and CMR] will be helpful in detecting recurrence, in which case a DOAC should be re-initiated for an indefinite period of time.

I would stop DOAC after 6 months and use DAP and then reimage in 3 weeks off DOAC.

LV thrombus with hypokinesia requires lifelong anticoagulation, even more so if the area is aneurysmal.