Researchers at the University Heart Center Freiburg-Bad Krozingen in Germany combed through fifteen years of hospital records, from January 2008 to December 2022, screening nearly twenty thousand patients admitted with acute myocardial infarction. Out of 19,964 patients, they confirmed left ventricular thrombus in 166 individuals, a hospital-based detection rate of just 0.83 percent. That figure is strikingly lower than the 5 to 12 percent incidence reported in older literature, and the authors attribute much of the decline to the modern era of rapid coronary reperfusion. In their center, patients were whisked to coronary angiography on the day of admission, with a median delay of zero days, restoring blood flow to starving heart muscle before extensive tissue death could create the stagnant, aneurysmal conditions in which clots flourish. The message is clear: the faster the artery is opened, the less likely the ventricle is to harbor a thrombus.

The typical patient profile in the study will be familiar to any cardiologist. Of the 160 patients included in the final analysis, 78 percent were men, the median age was 64 years, and 74 percent had presented with an ST-segment elevation myocardial infarction, the most severe form of heart attack. Two-thirds had anterior infarctions, the variety most notorious for damaging the heart’s apex and creating the wall-motion abnormalities that promote clot formation. Echocardiography revealed that the median left ventricular ejection fraction at diagnosis was a markedly reduced 35 percent, and 89 percent of the thrombi were located at the apex, the anatomical dead zone where blood tends to pool when the muscle beneath it stops contracting. Most clots were described as organized rather than fresh, with a median diameter of 20 millimeters, and nearly nine in ten patients had a single thrombus rather than multiple deposits.

Diagnosing these clots remains a technical challenge. Transthoracic echocardiography is the workhorse screening tool, but the cardiac apex can be notoriously difficult to visualize, and guidelines increasingly recommend contrast agents to sharpen the image. Cardiac magnetic resonance imaging with gadolinium remains the gold standard, boasting sensitivity up to 88 percent and perfect specificity. In this cohort, contrast-enhanced echocardiography was used in only 7 percent of cases, something the authors acknowledge may have limited detection, particularly since much of the study period predates the latest guideline recommendations. The researchers suggest that clinicians should aim not merely to detect a thrombus but to measure it precisely, because their regression analysis revealed that initial thrombus size was the only significant predictor of whether the clot would dissolve: each larger clot carried roughly half the odds of complete resolution, with an odds ratio of 0.55.

Treatment of left ventricular thrombus has long rested on oral anticoagulation, with guidelines recommending at least three to six months of therapy followed by repeat imaging to assess regression. For decades, the only option was a vitamin-K antagonist such as warfarin, a drug that is effective but notoriously fickle, demanding regular blood monitoring and interacting with countless medications and foods. The arrival of direct oral anticoagulants, or DOACs, beginning with dabigatran’s European approval in 2008, transformed anticoagulation across many fields of cardiology, but their role in ventricular thrombus remained uncertain because randomized evidence was scarce and trial sizes were small. The Freiburg-Bad Krozingen dataset captures this therapeutic transition in real time, and the prescribing patterns it documents tell a story of rapid cultural change within a single institution.

Between 2008 and 2016, vitamin-K antagonists dominated, accounting for between 73 and 100 percent of prescriptions at discharge. After 2016, the tide turned decisively: DOAC prescriptions climbed to 47 percent between 2017 and 2019 and reached 75 percent between 2020 and 2022, a shift the authors report as statistically significant. In the overall cohort, 85 patients were discharged on a vitamin-K antagonist, 49 on a DOAC, and 26 on other forms of anticoagulation such as heparin. Many patients also continued antiplatelet therapy, with roughly half receiving a single antiplatelet agent, usually clopidogrel, alongside their anticoagulant, and the other half on dual antiplatelet therapy, reflecting the delicate balancing act clinicians face when a patient needs protection against both clot formation in stents and clot dissolution in the ventricle.

The central question, of course, is whether the newer drugs actually work as well as the old ones in this specific setting. Among the 120 patients who returned for follow-up echocardiography within a year, 79 percent showed complete thrombus resolution. In the DOAC group, 87 percent of clots fully dissolved, compared with 79 percent under vitamin-K antagonists, a difference that did not reach statistical significance. Even among patients whose clots persisted, the majority, 70 percent, showed a measurable shrinkage, with a median reduction of nearly 6 millimeters. The analysis of antithrombotic intensity told a similar story: patients on dual antithrombotic therapy and those on triple therapy achieved nearly identical resolution rates, at 81.8 and 82.3 percent respectively. These real-world results align closely with the small randomized trials that have compared rivaroxaban or apixaban against warfarin, which consistently found comparable regression and safety between the drug classes.

Safety data from the first year after diagnosis underscore both the danger of the condition and the rough equivalence of the two strategies. The researchers documented 14 embolic events, 8 bleeding events of at least moderate severity, and 16 deaths among 25 patients who experienced clinical events. Embolic events clustered strikingly early, occurring a median of just 2.5 days after the thrombus was diagnosed, a finding that emphasizes how quickly these clots can declare themselves and how critical early anticoagulation is. Deaths also occurred early, at a median of 6 days after diagnosis, while bleeding events tended to appear later, at a median of 51 days. Comparing the drug classes, patients on vitamin-K antagonists experienced 7 clinical events, including 3 deaths, while DOAC patients experienced 3 events, with no statistically significant difference in survival between the groups. The authors are careful to note that the small event numbers limit the statistical power of these comparisons.

The study’s strengths lie in its scale and its longitudinal sweep. Screening nearly twenty thousand patients over fifteen years dwarfs most previous cohorts, and the availability of digital echocardiographic images and reports allowed independent review by two staff members, with missing measurements completed by a board-certified echocardiographer. Yet the retrospective design imposes real constraints. The specific diagnostic code for thrombus complicating acute myocardial infarction was applied in only a minority of cases, raising the possibility that the true incidence was underestimated due to coding inconsistencies. Clinical outcomes relied on hospital documentation rather than direct patient contact, and follow-up echocardiograms performed at outside centers could have been missed. The differing timing of follow-up examinations between groups, with DOAC patients re-examined after a median of 103 days versus 65 days for vitamin-K antagonist patients, may also have influenced the observed resolution rates.

For clinicians, the practical takeaways are nonetheless concrete. Left ventricular thrombus remains a serious complication of myocardial infarction even as its incidence falls, and the embolic events observed within days of diagnosis argue for vigilant early imaging in high-risk patients, particularly those with anterior infarcts and severely reduced ejection fractions. The data support the growing use of direct oral anticoagulants as a reasonable alternative to vitamin-K antagonists, offering comparable thrombus resolution and event rates without the burden of monitoring. The authors call for larger randomized controlled trials to confirm these findings definitively, and for standardized follow-up protocols so that patients with these hidden clots are tracked consistently. In the meantime, the study adds a substantial piece of real-world evidence to a field long starved of it, suggesting that the newer blood thinners have earned their place at the bedside of heart attack survivors facing this rare but formidable complication.

Subject of Research: Left ventricular thrombus after myocardial infarction: incidence, echocardiographic features, and anticoagulation outcomes

Article Title: Echocardiographic features, antithrombotic therapy, and association with outcomes in patients with left ventricular thrombus after myocardial infarction: a single-center retrospective study

Article References: Maslarska-Martens, M., Blank, C., Li, T., Wessinger, M., Hesselbarth, D., Gjermeni, D., Franke, K., Valina, C., Jander, N., Grundmann, S., Wolf, D., Westermann, D., & Olivier, C. B. (2026). Echocardiographic features, antithrombotic therapy, and association with outcomes in patients with left ventricular thrombus after myocardial infarction: a single-center retrospective study. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-026-03020-3

Image Credits: AI Generated

DOI: 10.1007/s00392-026-03020-3

Keywords: left ventricular thrombus, myocardial infarction, anticoagulation, direct oral anticoagulants, vitamin K antagonists, echocardiography, thrombus resolution, STEMI, embolism, cardiology, retrospective cohort study, bleeding events

The research team, led by Katerina Green and Deanna Menapace of the Department of Otolaryngology-Head and Neck Surgery, together with colleagues from dermatology and the Mayo Clinic Alix School of Medicine, conducted a systematic PubMed search that identified 19 published studies documenting adverse events associated with regenerative therapeutics in facial plastic surgery. They supplemented this literature analysis with a retrospective chart review of six patients treated at their own institution who experienced complications from these procedures. Their findings paint a detailed picture of what can go wrong when biologically active materials are injected into the highly vascular landscape of the face.

The technical appeal of these therapies is easy to understand. Platelet-rich plasma, or PRP, is derived from a patient’s own blood, which is centrifuged to concentrate platelets and the growth factors they carry. When injected into the skin or scalp, these factors stimulate angiogenesis and collagen synthesis, promoting tissue repair and regeneration. Nanofat, meanwhile, is produced by mechanically emulsifying harvested fat until mature adipocytes are broken down, leaving behind the stromal vascular fraction and adipose-derived stem cells with regenerative properties. Exosomes, tiny extracellular vesicles packed with signaling molecules, represent the newest frontier, marketed for anti-inflammatory and collagen-stimulating effects on skin texture and pore size.

Yet the review reveals that the most devastating complications share a common mechanism: vascular embolism. When injectable material enters an artery, it can travel retrograde into the ophthalmic artery and its branches, occluding blood supply to the retina or brain. The literature documents eight cases of vision loss following PRP injection, six of them permanent. Seven of these occurred after injections into the glabella, the region between the eyebrows where the supratrochlear and supraorbital arteries lie in close proximity to the ophthalmic system. Patients reported losing vision almost immediately, and central retinal artery occlusion is treatable only within an approximately four-hour window, a deadline frequently missed when injections occur in non-hospital settings.

Autologous fat grafting carries even greater documented risk. A systematic review cited in the paper identified 61 cases of arterial embolism after facial fat injection, including six deaths. In one reported case, an 18-year-old woman developed hemiplegia and loss of consciousness 24 hours after temporal fat injection; imaging revealed an infarction of the right external carotid artery caused by fat embolism, and despite decompressive craniotomy she died of central respiratory failure. In another, fat injected into the nasolabial fold entered the dorsal nasal artery and migrated to the ophthalmic artery, causing irreversible blindness. By contrast, nanofat injections appear far gentler: a review of 36 patients treated for periorbital dark circles found only transient bruising and mild edema, both resolving within days.

The Mayo Clinic cases add valuable new detail to this risk map. The first describes a 47-year-old woman who developed painful reactive lymphadenopathy the night after scalp PRP injections for hair loss, requiring emergency evaluation, CT imaging, and antibiotics before symptoms resolved. The authors suggest this may establish PRP alone, independent of microneedling with which it has previously been combined, as a trigger for lymph node swelling, possibly through local trauma or reaction to concentrated growth factors. The second case is the first of its kind: a 51-year-old woman developed facial tingling, numbness, and arm heaviness minutes after scalp PRP, prompting a full stroke workup. When imaging excluded ischemia, clinicians concluded she had experienced an acephalgic migraine with aura triggered by the procedure, a side effect never previously associated with PRP that may be relevant when injections follow trigeminal nerve distributions.

Three further institutional cases involved fat and nanofat. One patient who received temporal microfat and nanofat mixed with PRP developed delayed fat necrosis seven months after surgery, with a fluid collection that required serial aspiration and MRI confirmation, ultimately leaving the aesthetic result suboptimal. Two other patients developed nodular swelling after periorbital nanofat grafting; in one, intralesional triamcinolone resolved the nodules, while in the other persistent fullness required surgical excision, illustrating that treatment responses vary and clinical flexibility is essential. A sixth patient, treated with a topical human-derived exosome product after laser resurfacing, developed facial swelling and blistering consistent with suspected contact dermatitis, believed to be the first reported complication of topical exosome therapy in the United States.

The exosome literature emerging internationally is more concerning. Injectable exosome products are not approved by the US Food and Drug Administration, and their composition varies enormously between manufacturers depending on source material, isolation methods, and processing. Reported complications include granuloma formation, hypersensitivity reactions, persistent nodular lesions refractory to corticosteroids, and painful cutaneous necrosis that responded poorly even to carbon dioxide laser treatment. Notably, many of the severe reactions occurred after injections administered at private, non-hospital clinics, whereas a hospital-based retrospective series of 40 patients receiving exosome skin boosters with microneedling reported only expected erythema and edema resolving within 48 hours.

The authors emphasize that an underappreciated contributor to these complications is the profound heterogeneity of the products themselves. PRP preparation protocols differ in centrifugation speed, duration, and technique, producing wide variation in platelet concentration and cellular composition. Nanofat quality depends on harvesting location, instrumentation, and the number of emulsification passes. Exosome formulations differ in origin and purity. This variability limits reproducibility across studies and clinics, complicates comparisons of safety data, and means that two patients receiving nominally identical treatments may receive biologically distinct products. Regulatory frameworks have struggled to keep pace: the FDA regulates only minimally manipulated, homologous-use human cell products under 21 CFR 1271, PRP largely escapes the HCT/P framework as an autologous blood product, and recent state legislation such as a 2025 Florida law has expanded physician discretion to offer certain non-FDA-approved regenerative therapies.

Prevention, the authors argue, remains the most effective strategy because treatments for established embolic complications are notoriously unreliable. Ocular massage, anterior chamber paracentesis, intraocular pressure-lowering agents, hyaluronidase, hyperbaric oxygen, and intra-arterial thrombolysis have all been attempted for injection-related blindness, and none has proven consistently effective. Recommended safeguards include mapping vascular anatomy before procedures, avoiding bolus injections and previously traumatized sites, using small cannulas with low injection pressure and volume, employing ultrasound guidance where available, and maintaining an emergency protocol for immediate injection cessation with rapid referral to ophthalmology or emergency services. The researchers also call for candid discussion of risks in the literature, noting that favorable safety profiles and underreporting have combined to leave patients and providers underinformed. Their central message is measured rather than alarmist: PRP, fat grafting, and exosome therapies offer real aesthetic benefit when used with stewardship, but providers must understand each modality’s mechanism, screen patients for cardiovascular, hematological, and immunological risk factors, and prepare for the rare but catastrophic complications that these otherwise promising biologics can produce.

Subject of Research: Complications of regenerative medicine therapies, including platelet-rich plasma, fat and nanofat grafting, and exosomes, in facial plastic surgery

Article Title: Complications of regenerative therapeutics in facial plastic surgery: a case series and review of the literature

Article References: Green, K., Pascal, G. J., Tolaymat, L., Bruce, A., & Menapace, D. (2026). Complications of regenerative therapeutics in facial plastic surgery: a case series and review of the literature. BMC Plastic and Reconstructive Surgery, 2(1), Article 19. https://doi.org/10.1186/s44452-026-00032-w

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00032-w

Keywords: regenerative medicine, facial plastic surgery, platelet-rich plasma, fat grafting, nanofat, exosomes, blindness, embolism, aesthetic medicine, complications, PRP, cosmetic injections