# Left Ventricular Non-Compaction Cardiomyopathy-Still More Questions than Answers
## 7 Treatment  
LVNC has no specific therapy as of today. In the actual ESC guidelines for the treatment of heart failure, no special recommendations for the management of LVNC are given. Treatment should be applied depending on the clinical situation and specific indications. In patients with decreased LV EF, heart failure pharmacotherapy should be applied according to the guidelines [66]. In patients with end-stage heart failure refractory to medical therapy, heart transplantation should be considered. In patients with contraindication to heart transplantation, implantation of a left ventricular assist device can be an effective therapy option. Recently, [PERSON] and colleagues reported a successful surgical resection of non-compacted myocardium in a 65-year-old man with the improvement of systolic function of the left ventricle after a one-year follow-up [67]. By the current guidelines of ESC, there is no special indication for ICD implantation for patients with LVNC. Implantation of ICD should be considered in all patients with LV EF lower or equal to 35%, as in patients with dilatative cardiomyopathy. Implantation of an  
Figure 7: A pathway for risk stratification and follow-up of patients with hypertrabeculation phenotype. ICD results in cardiac arrest prevention and improved prognosis. Appropriate ICD therapy was reported in 67% of patients [66]. In patients with LVNC and advanced heart failure who fulfill general criteria for resynchronization therapy (CRT), implantation of CRT should be considered. In responders, implantation of CRT in overall improvement of the ejection fraction and reverse remodeling of heart muscle tissue was reported [68; 69]. Recurrent arrhythmias may be treated with transcatheter ablation. [PERSON] et al. and [PERSON] et al. reported good results in the ablation of VA substrates in patients with LVNC and VT with good VA control in long-term follow-up [70; 71]. Ablation may also be considered in the case of atrial fibrillation; however, no long-term follow-up data are available. Ablation may be considered as well in other co-existing with LVNC abnormalities, such as WPW. According to the study by [PERSON] and colleagues, thromboembolic complications in patients with LVNC can reach 38% [72]. In the retrospective analysis of 169 patients, thromboembolic complications were noted in 15% [23]. The cardiac source of embolism was found in 69% of patients; however, atrial fibrillation was found in only 39% of them. Excessive trabeculation of the left ventricle was found to be a risk factor for thromboembolic risk. A 5% increase in the volume of non-compacted myocardium was associated with a ninefold risk of thromboembolic events [73]. In the prevention of embolic events, both VKA (vitamin K antagonists) and NOAC (non-vitamin K antagonist oral anticoagulant) drugs may be considered. In the group of patients with LVNC and coexisting atrial fibrillation or a history of embolic events, NOAC is the first choice. In patients with left ventricular thrombus, VKA are the drugs of choice. There is no agreement as to whether patients with left ventricular dysfunction without previous history of atrial fibrillation should be treated with anticoagulants. In the randomized WARCEF study 2305 patients with EF < 35% and sinus rhythm were randomized to Warfarin (INR 2.0-3.0) and Aspirin 325 mg and followed up for 6 years. The primary outcome was the time to the first event in a composite endpoint of ischemic stroke, intracerebral hemorrhage, or death from any cause. No significant overall difference between the two treatments could be found. Warfarin was statistically more effective in the reduction in ischemic stroke (0.72 events per 100 patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; \(p\) = 0.005); however, the incidence of major hemorrhage was significantly higher in the Warfarin group what offset its beneficial effect [74]. A negative correlation of risk of embolic events with EF was found [75].