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

A common and sometimes challenging scenario. If there is persistent LV dysfunction (EF <40%) with apical akinesis /aneurysm, I maintain anticoagulation regardless of thrombus resolution. Recurrence of thrombus, even after echo imaging evidence of resolution in this state has been observed. There is also some data suggesting that even with ultrasound enhancing agents, we can miss thrombus on echo in these patients when compared to CMR.

Obviously each patient needs to be individualized based on risk/benefit and bleeding risk. Similar to a prior comment, I will also use DOACs after initial evidence of thrombus resolution if planning on maintaining longer term OAC.

There is no good data to guide surveillance in this cases. If the patient remains with low EF and an akinetic apex, I usually don't stop anticoagulation at all as long as they are tolerating. This is simply because being wrong on this would be an intolerable outcome.

If the LV function improves with time but there is still an area of akinesis, I would stop anticoagulation after resolution of the thrombus and repeat the echo with contrast in roughly 3 months time. If, however, the thrombus resolved but there is still "sludge" on the echo in that region, I will continue AC.

And I use DOACs with great success anecdotally. No data for that.