Heightened interest in left ventricular thrombus (LVT) stems from the consistent association of subsequent stroke and systemic embolism after LVT, and many aspects of its management still exist in a grey area of evidence. The current delay in intervention is likely related to a limited understanding of the disease pathophysiology, along with an underestimation of LVT by standard imaging modalities. With the rapid development of antithrombotic regimens consisting of direct oral anticoagulants (OACs), which have shown early safety and efficacy, there is a growing need to understand and accurately diagnose the LVT process in order to determine appropriate management solutions. This educational review will oversee LVT pathophysiology, current status of the guidelines-recommended echocardiographic approach and the role of multimodality imaging, as well as prevention and treatment modalities in the modern era. Meanwhile, the review proposes an algorithm for the prevention and treatment of LVT based on current guidelines and expert consensus, and highlights the need for more investigations to identify risk stratification methods for individual patients, and lastly, discusses the potential of direct OACs in the management of LVT.