Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?

I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve.

Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV thrombus.

Furthermore, there have been a few small studies showing that there is at least noninferiority of DOAC vs. VKA.

2328 consecutive coronary angio +/- PCI for AMI with 101 found to have LV thrombus - 60 on VKA, 41 on NOAC. Better and sooner thrombus resolution on NOAC with lower bleeding risk.

Jones et al., PMID 32730627

Prospective RCT (albeit very small)
17 randomized to warfarin, 18 to apixaban
1 in apixaban group died
Of survivors, 16/17 had...

You will not find a class I indication for using DOAC in LV thrombus because there is not likely to be a randomized, double-blinded clinical trial on this indication. The small number of patients involved will not provide enough quality data or incentive for the companies to apply for an additional indication with the FDA. Therefore, the use of DOAC in LV thrombus is going to be off-label for as far as you could imagine.

I prefer using DOAC over warfarin for LV thrombus. If DOAC works for left atrial appendage thrombus, it would likely work for LV thrombus as well. With warfarin, you run the risk of having subtherapeutic INR in the real clinical settings. Some patients may not comply with the at least monthly blood test and dietary restricti...

The current standard of care of LV thrombus is anticoagulation with warfarin. Use of DOACs for LV thrombi is an off-label indication and observational data has shown this to be inferior to warfarin. I would only consider DOAC in this situation for patients who refuse warfarin or cannot comply with the routine monitoring, dietary restrictions, etc to maintain a therapeutic INR.

Robinson et al., PMID 32320043