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Kołakowski K, Farkowski MM, Pytkowski M, Gardziejczyk P, Kowalik I, Dąbrowski R, Firek B, Jaworski K, Klisiewicz A, Maciąg A. The Comparative Effectiveness and Safety of Different Anticoagulation Strategies for Treatment of Left Atrial Appendage Thrombus in the Setting of Chronic Anticoagulation for Atrial Fibrillation or Flutter. Cardiovasc Drugs Ther 2023; 37:159-168. [PMID: 34669102 PMCID: PMC9834361 DOI: 10.1007/s10557-021-07278-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE To compare effectiveness of different treatments for atrial fibrillation (AF) patients who were scheduled for cardioversion (CV) or ablation (CA) presenting with left atrium appendage (LAA) thrombus despite chronic oral anticoagulation therapy (OAC). METHODS This was a retrospective cohort study. We analyzed 2014-2019 medical records of patients scheduled for CV or CA of AF who were diagnosed with LAA thrombus despite optimal OAC and had a follow-up transesophageal echocardiogram (TOE). Changes in treatment were divided into the following groups: switch to a drug with different mechanism of action, switch to a drug with similar mechanism of action, initiation of combination therapy, or deliberate no change in treatment. Patients with contraindications to non-vitamin K antagonists were excluded from the analysis. RESULTS We analyzed data of 129 patients comprising 181 cycles of treatment. The overall effectiveness of LAA thrombus dissolution was 51.9% regardless of the number of cycles and 42.6% for the first cycle of treatment. Any change of treatment was more effective than deliberate no change-OR 2.97 [95% CI: 1.07-8.25], P = 0.031, but no particular strategy seemed to be more effective than the other. Left atrium area (OR 0.908 [95% CI: 0.842-0.979]) and number of treatment cycles (OR 0.457 [95% CI: 0.239-0.872]) were both adversely related to thrombus resolution. There was one ischemic and three bleeding adverse events during the treatment. CONCLUSION LAA thrombus resolution in patients already on OAC may require a change of previous OAC treatment but the overall effectiveness of dissolution seems to be about 50%.
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Affiliation(s)
- Karol Kołakowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - Michał M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland.
| | - Mariusz Pytkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - Piotr Gardziejczyk
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - Ilona Kowalik
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Rafał Dąbrowski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Bohdan Firek
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Krzysztof Jaworski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Anna Klisiewicz
- Department of Congenital Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - Aleksander Maciąg
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
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Badescu MC, Sorodoc V, Lionte C, Ouatu A, Haliga RE, Costache AD, Buliga-Finis ON, Simon I, Sorodoc L, Costache II, Rezus C. Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus. J Pers Med 2023; 13:jpm13010158. [PMID: 36675819 PMCID: PMC9866081 DOI: 10.3390/jpm13010158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/17/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
In recent years, direct oral anticoagulants (DOAC) have accumulated evidence of efficacy and safety in various clinical scenarios and are approved for a wide spectrum of indications. Still, they are currently used off-label for left ventricular thrombus owing to a paucity of evidence. For the same reason, there is a lack of guideline indication as well. Our work is based on an exhaustive analysis of the available literature and provides a structured and detailed update on the use of DOACs in patients with left ventricle thrombus. The safety and efficacy of DOACs were analyzed in particular clinical scenarios. As far as we know, this is the first paper that analyzes DOACs in this approach.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Victorita Sorodoc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
- Correspondence: (V.S.); (C.L.)
| | - Catalina Lionte
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
- Correspondence: (V.S.); (C.L.)
| | - Anca Ouatu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Raluca Ecaterina Haliga
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Alexandru Dan Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiovascular Rehabilitation Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ioan Simon
- Department of Surgery, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Laurentiu Sorodoc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
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A Prospective Study to Evaluate the Effectiveness of Edoxaban for the Resolution of Left Atrial Thrombosis in Patients with Atrial Fibrillation. J Clin Med 2022; 11:jcm11071945. [PMID: 35407553 PMCID: PMC8999540 DOI: 10.3390/jcm11071945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Available evidence on left atrial (LA) thrombus dissolution in patients with atrial fibrillation (AF) largely refers to the use of vitamin K antagonist oral anticoagulants (VKAs), showing >50% thrombus resolution over a 4-week to 12-month treatment period. Available data on non-vitamin K antagonist anticoagulants (NOACs) in this setting are limited and derive from isolated case reports or observational small-sized investigations with dabigatran, rivaroxaban or apixaban. The aim of this study was to investigate the extent of thrombus resolution with edoxaban therapy in patients with AF and LA thrombosis. We conducted a prospective, observational, open-label pilot study in seven Italian institutions. We included a total of 25 patients with non-valvular AF and LA (or left atrial appendage (LAA)) thrombosis, documented by transesophageal echocardiography (TEE). All patients received edoxaban OD treatment (n = 23 on 60 mg daily; n = 2 on 30 mg daily) and underwent TEE examination after 4 weeks. The primary endpoint was the percentage of patients with complete thrombus resolution by TEE imaging at 4 weeks. The mean age of the study population was 68.3 ± 10.8 years with a female population of 16%. AF was permanent in all cases, with a mean arrhythmia duration of 4.3 ± 1.7 years. CHA2DS2-VASc and HAS-BLED scores were 3.2 ± 1.5 and 1.9 ± 1.1, respectively. We were able to demonstrate a complete thrombus resolution in 14 patients (56%) at 4 weeks. In patients with residual atrial thrombosis (n = 11), we observed a 15.4 ± 14.9% reduction in the thrombus area from baseline. As compared with patients without thrombus dissolution, those with thrombus resolution had a numerically lower-indexed LA diameter (27.9 ± 9.3 vs 34.8 ± 16.1 mm/m2), a smaller maximum thrombus area at baseline (45.5 ± 44.6 vs 63.9 ± 43.5 mm2), a higher left ventricular ejection fraction (47.4 ± 21.0% vs 38.4 ± 20.6%) and higher maximum LAA flow velocities (26.3 ± 15.2 vs 19.3 ± 10.0 cm/s). Figures on the percentage of thrombus resolution in this study are comparable to those reported in the literature for the other OACs. We conclude that, in patients with AF, the use of edoxaban is associated with a >50% resolution of atrial thrombus at 4 weeks, similar to studies using VKAs and the other NOACs (ClinicalTrials.gov identifier number: NCT034899395).
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Abdelnabi M, Benjanuwattra J, Okasha O, Almaghraby A, Saleh Y, Gerges F. Switching from warfarin to direct-acting oral anticoagulants: it is time to move forward! Egypt Heart J 2022; 74:18. [PMID: 35347478 PMCID: PMC8960500 DOI: 10.1186/s43044-022-00259-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/20/2022] [Indexed: 11/12/2022] Open
Abstract
Oral vitamin K antagonists (VKAs), warfarin, have been in routine clinical use for almost 70 years for various cardiovascular conditions. Direct-Acting Oral Anticoagulants (DOACs) have emerged as competitive alternatives for VKAs to prevent stroke in patients with non-valvular atrial fibrillation (AF) and have become the preferred choice in several clinical indications for anticoagulation. Recent guidelines have limited the use of DOACs to patients with non-valvular AF to reduce the risk of cardioembolic complications and to treat venous thromboembolism (VTE). Although emerging evidence is suggestive of its high efficacy, there was a lack of data to support DOACs safety profile in patients with mechanical valve prosthesis, intracardiac thrombi, or other conditions such as cardiac device implantation or catheter ablation. Therefore, several clinical trials have been conducted to assess the beneficial effects of using DOACs, instead of VKAs, for various non-guideline-approved indications. This review aimed to discuss the current guideline-approved indications for DOACs, advantages, and limitations of DOACs use in various clinical indications highlighting the potential emerging indications and remaining challenges for DOACs use. Several considerations are in favour of switching from warfarin to DOACs including superior efficacy, better adverse effect profile, fewer drug-drug interactions, and they do not require frequent international normalized ratio (INR) monitoring. Large randomized controlled trials are required to determine the safety and efficacy of their use in various clinical indications.
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Affiliation(s)
- Mahmoud Abdelnabi
- Internal Medicine Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA. .,Cardiology and Angiology Unit, Clinical and Experimental Internal Medicine Department, Alexandria University, Alexandria, Egypt.
| | - Juthipong Benjanuwattra
- Internal Medicine Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Osama Okasha
- Internal Medicine Department, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Abdallah Almaghraby
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yehia Saleh
- Cardiology Department, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Fady Gerges
- Department of Cardiovascular Science, Mediclinic Al Jowhara Hospital, Al Ain, UAE
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Naser JA, Arghami A, Eleid MF, Pislaru SV. Severe tricuspid bioprosthetic valve stenosis as an unusual cause of pulmonary embolism: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab169. [PMID: 34124568 PMCID: PMC8189298 DOI: 10.1093/ehjcr/ytab169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/18/2021] [Accepted: 04/07/2021] [Indexed: 12/03/2022]
Abstract
Background Bioprosthetic tricuspid valve stenosis (TS) is an uncommon and frequently under-diagnosed condition. Although the resulting right heart failure symptoms are well-known, the associated thrombogenic potential is under-recognized. Case summary A 44-year-old woman with bioprosthetic tricuspid valve (TV) replacement in 2001 was referred for urgent consultation due to acute worsening of dyspnoea and severe swelling and pain in her left arm and neck. She was diagnosed with atrial fibrillation 6 months before the presentation and was found to have right atrial (RA) thrombus with pulmonary embolism and extensive retrograde venous extension 1 month prior. Review of studies done at her local institution revealed 10 mmHg mean gradient (MG) across the bioprosthetic TV that was only reported as mild–moderate TS. Echocardiography done at our instruction confirmed suspicion of severe TS with calcified immobile leaflets. Computed tomography showed persistent RA thrombus and therefore surgical replacement of the TV was undertaken. Subsequently, patient’s dyspnoea rapidly improved. Discussion Progressive dyspnoea and symptoms of right heart failure in a patient with a history of bioprosthetic TV replacement should be investigated for prosthetic valve dysfunction. Due to its rarity, TS diagnosis can be overlooked on routine echocardiography. In our patient, despite a measured MG of 10 mmHg, the presence of critical TS was not initially recognized. As TS is associated with increased thrombogenic potential and given the rare occurrence of in situ RA thrombosis, physicians must have a high index of suspicion for TS in the appropriate clinical context.
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Affiliation(s)
- Jwan A Naser
- Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Zhang H, Yu M, Xia Y, Li X, Liu J, Fang P. The differences of atrial thrombus locations and variable response to anticoagulation in nonvalvular atrial fibrillation with ventricular cardiomyopathy. J Arrhythm 2020; 36:1016-1022. [PMID: 33335618 PMCID: PMC7733561 DOI: 10.1002/joa3.12422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES This study aims to research the clinical features of atrial thrombi in patients with nonvalvular atrial fibrillation (AF). METHODS This study included 191 patients of AF who had atrial thrombi. One hundred and twenty-eight of them were assigned into nonventricular cardiomyopathy group (non-VCM), and the remaining 63 into ventricular cardiomyopathy group (VCM). After atrial thrombi diagnosed, all patients had taken oral anticoagulant therapy. The resolution rates of thrombi within 12 months were compared between the two groups, as well as the locations of thrombi. RESULTS Of all 191 patients, 161 had thrombi only detected in left atrial appendage (LAA), 20 in both left atrium (LA) and LAA, six in LA only, and four in right atrium only. More patients had thrombi out of LAA in the VCM group than in the non-VCM group (30.2% vs 8.6%, P < .001). After propensity score matching, the atrial thrombi were resolved faster in the non-VCM group than in the VCM group (mean time length: 22 ± 2 weeks vs 30 ± 3 weeks, P = .038), and the resolution rate within 12 months was higher in the non-VCM group than in the VCM group (88.7% vs 61.4%, Log-rank, P = .038). In Cox proportional hazards model, absence of ventricular cardiomyopathy was an independent predictor for the resolution of atrial thrombus (hazard ratio: 1.76; P = .035). CONCLUSIONS The patients of atrial fibrillation with ventricular cardiomyopathies have higher incidence of thrombosis in the body of left atrium or right atrium. And the resolution rate was lower in these patients.
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Affiliation(s)
- Hao Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
- Department of CardiologyChongqing General HospitalUniversity of Chinese Academy of SciencesChongqingChina
| | - Miao Yu
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Yu Xia
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Xiaofeng Li
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Jun Liu
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Pihua Fang
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
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Fink T, Ouyang F, Heeger CH, Sciacca V, Reissmann B, Keelani A, Schütte C, Wohlmuth P, Maurer T, Rottner L, Eitel C, Eitel I, Rillig A, Metzner A, Kuck KH, Tilz RR, Vogler J. Management of thrombus formation after electrical isolation of the left atrial appendage in patients with atrial fibrillation. Europace 2020; 22:1358-1366. [DOI: 10.1093/europace/euaa174] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 06/02/2020] [Indexed: 12/30/2022] Open
Abstract
Abstract
Aims
Left atrial appendage (LAA) electrical isolation (LAAEI) in addition to pulmonary vein isolation is an emerging catheter-based therapy to treat symptomatic atrial fibrillation. Previous studies found high incidences of LAA thrombus formation after LAAEI. This study sought to analyse therapeutic strategies aiming at the resolution of LAA thrombi and prevention of thromboembolism.
Methods and results
Left atrial appendage electrical isolation was conducted via creation of left atrial linear lesions or cryoballoon ablation. Follow-up including transoesophageal echocardiography was conducted. In patients with LAA thrombus, oral anticoagulation (OAC) was adjusted until thrombus resolution was documented. Percutaneous LAA closure (LAAC) under use of a cerebral protection device was conducted in case of medically refractory LAA thrombi. Left atrial appendage thrombus was documented in 54 of 239 analysed patients who had undergone LAAEI. Thrombus resolution was documented in 39/51 patients (72.2%) with available follow-up after adjustment of OAC. Twenty-nine patients underwent LAAC and 10 patients were kept on OAC after LAAEI. No thromboembolic events or further LAA thrombi were documented after 553 ± 443 days of follow-up in these patients. Persistent LAA thrombi despite adaption of OAC was documented in 12/51 patients. One patient remained on OAC until the end of follow-up, while LAAC with a cerebral protection device was performed in 11 patients in the presence of LAA thrombus without complications.
Conclusion
Left atrial appendage thrombus formation is common after LAAEI. Adjustment of OAC leads to LAA thrombus resolution in most patients. Left atrial appendage closure in the presence of LAA thrombi might be a feasible option in case of failed medical treatment.
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Affiliation(s)
- Thomas Fink
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Feifan Ouyang
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Center of Cardiac Arrhythmias, Fuwai Hospital of the Chinese Academy of Medical Sciences, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Christian-Hendrik Heeger
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Germany
| | - Vanessa Sciacca
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Bruno Reissmann
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Cardiac Electrophysiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Ahmad Keelani
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | | | - Peter Wohlmuth
- Asklepios Proresearch, Lohmühlenstraße 5, 20099 Hamburg, Germany
| | - Tilman Maurer
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Laura Rottner
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Cardiac Electrophysiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Charlotte Eitel
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Ingo Eitel
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Andreas Rillig
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Cardiac Electrophysiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Cardiac Electrophysiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Germany
| | - Roland Richard Tilz
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Germany
| | - Julia Vogler
- Department of Cardiology, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
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Calabrò P, Gragnano F, Cesaro A, Marsico F, Pariggiano I, Patti G, Moscarella E, Cavallari I, Sardu C, Parato VM, Renda G, Niccoli G, Marcucci R, De Caterina R. Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and atrial thrombosis: An appraisal of current evidence. Arch Cardiovasc Dis 2020; 113:642-651. [PMID: 32712202 DOI: 10.1016/j.acvd.2020.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 12/14/2022]
Abstract
Major thromboembolic complications in patients with atrial fibrillation, secondary to thromboembolism from the left atrium or the left atrial appendage, are a major concern because of their burden of disabling stroke and mortality. To date, non-vitamin K antagonist oral anticoagulants (NOACs) are considered the first-line strategy in most patients with atrial fibrillation receiving chronic anticoagulation, as they have major advantages compared with vitamin K antagonists, including minimization of intracranial bleeding risk. Although several studies and post-hoc analyses have provided initial data on the use of NOACs in patients with documented atrial and/or left atrial appendage thrombosis, the benefit of NOACs in these patients has not been fully elucidated. In this review, we reappraise current evidence supporting the use of NOACs in patients with established atrial and/or left atrial appendage thrombosis, discussing potential mechanisms favouring the use of a NOAC-based strategy in this special setting.
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Affiliation(s)
- Paolo Calabrò
- Division of Cardiology, AORN Sant'Anna e San Sebastiano, 81100 Caserta, Italy; Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Felice Gragnano
- Division of Cardiology, AORN Sant'Anna e San Sebastiano, 81100 Caserta, Italy; Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Arturo Cesaro
- Division of Cardiology, AORN Sant'Anna e San Sebastiano, 81100 Caserta, Italy; Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Fabio Marsico
- Department of Advanced Biomedical Sciences, University Federico II, 80138 Naples, Italy
| | - Ivana Pariggiano
- Division of Cardiology, AORN Sant'Anna e San Sebastiano, 81100 Caserta, Italy; Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | | | - Elisabetta Moscarella
- Division of Cardiology, AORN Sant'Anna e San Sebastiano, 81100 Caserta, Italy; Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Ilaria Cavallari
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Vito Maurizio Parato
- Cardiology Unit, Madonna del Soccorso Hospital, 62074 San Benedetto del Tronto, Italy
| | - Giulia Renda
- Institute of Cardiology, Gabriele d'Annunzio University, 66100 Chieti, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
| | - Raffaele De Caterina
- University Cardiology Division, University of Pisa, Pisa University Hospital, 56124 Pisa, Italy; Fondazione VillaSerena per la Ricerca, 65013 Città Sant'Angelo, Italy.
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9
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Sakuwa M, Aozasa Y, Suto Y, Fukuda H. [Surgical considerations for two patients with cardioembolic stroke and mobile thrombus in the left atrium appendage]. Rinsho Shinkeigaku 2020; 60:278-284. [PMID: 32238747 DOI: 10.5692/clinicalneurol.cn-001394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Two men (Case 1, 74 years old; Case 2, 65 years old) developed cardioembolic stroke due to self-interruption of anticoagulants for treating atrial fibrillation. They both had mobile thrombus in the left atrial appendage. In Case 1, a left atrial thrombectomy was scheduled on day 8, but infarction re-occurred on the morning of the the surgery, producing neurological sequelae. In Case 2, left atrial thrombectomy and left atrial appendage closure were performed successfully on day 8. The indication and timing of cardiac thrombectomy after the onset of cerebral infarction have not been standardized, and they seem to differ among individuals. Therefore, in the future, the optimal timing of left atrial thrombectomy should be decided based on the size and morphology of the left atrial thrombus, the size of the cerebral infarction and the presence or absence of hemorrhagic infarction.
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Affiliation(s)
- Mayuko Sakuwa
- Department of Neurology, Japanese Red Cross Matsue Hospital
| | - Yuki Aozasa
- Department of Neurology, Japanese Red Cross Matsue Hospital
| | - Yutaka Suto
- Department of Neurology, Japanese Red Cross Matsue Hospital
| | - Hiroki Fukuda
- Department of Neurology, Japanese Red Cross Matsue Hospital
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Yang Y, Du X, Dong J, Ma C. Outcome of Anticoagulation Therapy of Left Atrial Thrombus or Sludge in Patients With Nonvalvular Atrial Fibrillation or Flutter. Am J Med Sci 2019; 358:273-278. [DOI: 10.1016/j.amjms.2019.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 01/02/2023]
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11
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Loh CH, Herkes G. Republished: Successful thrombolysis for acute ischaemic stroke after reversal of dabigatran etexilate with idarucizumab. Drug Ther Bull 2019; 57:141-143. [PMID: 31444223 DOI: 10.1136/dtb.2019.229128rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In conjunction with BMJ Case Reports, DTB will feature occasional drug-related cases that are likely to be of interest to readers. These will include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlight unusual reactions to drugs that have been marketed for several years.
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Affiliation(s)
- Chee Hoou Loh
- Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Geoffrey Herkes
- Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
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Diagnosis and Management of Left Atrium Appendage Thrombosis in Atrial Fibrillation Patients Undergoing Cardioversion. ACTA ACUST UNITED AC 2019; 55:medicina55090511. [PMID: 31438560 PMCID: PMC6780583 DOI: 10.3390/medicina55090511] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/04/2019] [Accepted: 08/19/2019] [Indexed: 01/29/2023]
Abstract
Atrial fibrillation is the most common cardiac arrhythmia and is associated with an increased risk of stroke and thromboembolic complications. A rhythm control strategy with both electrical and pharmacological cardioversion is recommended for patients with symptomatic atrial fibrillation. Anticoagulant therapy for 3–4 weeks prior to cardioversion is recommended in order to avoid thromboembolic events deriving from restoring sinus rhythm. Transesophageal echocardiography has a pivotal role in this setting, excluding the presence of left atrial appendage thrombus before cardioversion. The aim of this review is to discuss the epidemiology and risk factors for left atrial appendage thrombosis, the role of echocardiography in the decision making before cardioversion, and the efficacy of different anticoagulant regimens on the detection and treatment of left atrial appendage thrombosis.
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Loh CH, Herkes G. Successful thrombolysis for acute ischaemic stroke after reversal of dabigatran etexilate with idarucizumab. BMJ Case Rep 2019; 12:e229128. [PMID: 31061182 PMCID: PMC6506077 DOI: 10.1136/bcr-2018-229128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 01/01/2023] Open
Abstract
We report the experience of reversing dabigatran prior to administering systemic thrombolysis for acute ischaemic cerebellar stroke, which was well tolerated with no haemorrhagic complications after thrombolysis. Given the increasingly common use of dabigatran for atrial fibrillation, the use of idarucizumab to reverse of dabigatran is a novel treatment that should be considered as an important adjunct to facilitate thrombolysis for ischaemic strokes and minimise haemorrhagic complications.
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Affiliation(s)
- Chee Hoou Loh
- Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Geoffrey Herkes
- Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
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Miyazawa K, Lip GYH. Risk assessment and management of atrial fibrillation patients with left atrial thrombus. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 42:1-3. [PMID: 30488453 DOI: 10.1111/pace.13556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Kazuo Miyazawa
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Lee WC, Fang CY, Chen YL, Fang HY, Chen HC, Liu WH, Fu M, Chen MC. Left Atrial or Left Atrial Appendage Thrombus Resolution After Adjustment of Oral Anticoagulant Treatment. J Stroke Cerebrovasc Dis 2018; 28:90-96. [PMID: 30301596 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 07/30/2018] [Accepted: 09/08/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND There are few reports about non-vitamin K antagonist oral anticoagulant (NOAC) treatment for resolution of left atrium (LA) or left atrial appendage (LAA) thrombus. LAA thrombus is an important cause of cardiogenic cerebral thromboembolism, and the detection rate increases due to more and more patients receiving catheter ablation. However, the results from NOAC use for LA or LAA thrombus are still unknown in real-world practice. The aim of this study was to discover the resolution of LA or LAA thrombus after anticoagulant treatment in real-world practice. METHOD From January 2013 to December 2016, a total 864 patients underwent transesophageal echocardiography (TEE), and 41 cases of LA or LAA thrombus were detected in our hospital. Among them, a total of 22 patients underwent follow-up TEE to detect the resolution of LA or LAA thrombus. RESULT The average age of the study patients was 72.0 ± 11 years old, and 61% were male. The average CHA2DS2-VASc scores were 3.76 ± 2.01 points. A total of 22 patients underwent follow-up TEE, and 19 (86.4%) patients presented LA or LAA thrombus resolution. The average resolution duration was 258.47 ± 218.17 days. One-year all-cause mortality was 4.9%, and the incidence of ischemic stroke was 4.9%. Most physicians favored titration of the dosage of NOAC or warfarin in real-world practice. CONCLUSION In real-world practice, most physicians favored titration of the dosage of NOAC or warfarin for LA or LAA thrombus. LA or LAA thrombus could exist if the patient received a reduced dose of NOAC. High frequency of LAA or LA thrombi could resolve, and a low incidence of ischemic stroke occurred after adjustment of oral anticoagulant treatment.
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Affiliation(s)
- Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City, Taiwan, Republic of China
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City, Taiwan, Republic of China
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City, Taiwan, Republic of China
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City, Taiwan, Republic of China
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City, Taiwan, Republic of China
| | - Wen-Hao Liu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City, Taiwan, Republic of China
| | - Morgan Fu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City, Taiwan, Republic of China
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City, Taiwan, Republic of China.
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Miyazawa K, Pastori D, Hammerstingl C, Cappato R, Meng IL, Kramer F, Cohen A, Schulz A, Eickels MV, Lip GYH, Marin F. Left atrial thrombus resolution in non-valvular atrial fibrillation or flutter: biomarker substudy results from a prospective study with rivaroxaban (X-TRA). Ann Med 2018; 50:511-518. [PMID: 29956554 DOI: 10.1080/07853890.2018.1495337] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants including rivaroxaban are widely used for stroke prevention in patients with atrial fibrillation (AF). We investigated the relationship between plasma biomarkers (indicative of thrombogenesis, fibrinolysis and inflammation) and left atrial thrombus resolution after rivaroxaban treatment. METHODS This was an ancillary analysis of the X-TRA study, which was a prospective interventional study evaluating the use of rivaroxaban for left atrial/left atrial appendage (LA/LAA) thrombus resolution in AF patients. We assessed various biomarkers of thrombogenesis/fibrinolysis [D-dimer, plasminogen activator inhibitor-1 (PAI-1), prothrombin fragment 1 + 2 (F1,2), thrombin-antithrombin (TAT) complexes, von Willebrand factor (vWF)] and inflammation [high-sensitivity interleukin-6 (hsIL-6), and high-sensitivity C-reactive protein (hsCRP)], measured at baseline and after 6 weeks' of rivaroxaban treatment. RESULTS There was a significant decrease in the mean levels of hsCRP, D-dimer, vWF, and TAT from baseline to end of treatment with rivaroxaban. Although none of the thrombogenesis/fibrinolysis biomarkers showed a significant relationship with thrombus resolution, high inflammatory biomarkers at baseline were significantly associated with an increased chance of the thrombus being completely resolved (hsIL-6) or reduced/resolved (hsCRP). CONCLUSIONS Biomarkers of inflammation are significantly associated with LA/LAA thrombus outcomes in AF patients prospectively treated with rivaroxaban.
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Affiliation(s)
- Kazuo Miyazawa
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK
| | - Daniele Pastori
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Department of Internal Medicine and Medical Specialties, I Clinica Medica, Atherothrombosis Centre , Sapienza University of Rome , Rome , Italy
| | - Christoph Hammerstingl
- c Department of Medicine II , Heart Centre Bonn, University Hospital Bonn , Bonn , Germany
| | | | | | - Frank Kramer
- e Global Medical Affairs, Bayer AG , Berlin , Germany
| | - Ariel Cohen
- f Cardiology Department , Assistance publique-Hôpitaux de Paris and Université Pierre-et-Marie-Curie, Saint-Antoine University and Medical School , Paris , France
| | - Anke Schulz
- g Research and Clinical Sciences Statistics, Bayer AG , Berlin , Germany
| | | | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,h Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - Francisco Marin
- i Department of Cardiology , Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBER-CV , Murcia , Spain
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Left atrial thrombus despite continuous direct oral anticoagulant or warfarin therapy in patients with atrial fibrillation: insights into rates and timing of thrombus resolution. J Interv Card Electrophysiol 2018; 53:159-167. [PMID: 30078133 DOI: 10.1007/s10840-018-0432-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Left atrial thrombus (LAT) may be detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation (AF) or flutter (AFL) despite continuous anticoagulation therapy. We sought to examine the rates and timing of LAT resolution in response to changes in anticoagulation regimen. METHODS A retrospective study of 1517 consecutive patients on ≥ 4 weeks continuous oral anticoagulation (OAC) undergoing TEE prior to either direct current cardioversion or catheter ablation for AF or AFL was performed. Patients who had LAT on index TEE imaging and had follow-up TEEs were analyzed. RESULTS Despite ≥ 4 weeks of continuous anticoagulation therapy, 63 (4.2%) patients had LAT. Forty-four patients (median age 67 [IQR 58, 74]; 33 [75%] male; 25 [57%] on direct oral anticoagulant [DOAC]) had follow-up TEEs performed. Upon detection of LAT on index TEE, 8 patients switched from warfarin to a DOAC, 21 patients switched from a DOAC to warfarin or another DOAC, and 15 patients remained on the same OAC. Over median 4.2 months (IQR 2.9, 6.6), LAT resolution was seen in 25 (57%) patients. Of the 25 patients who had LAT resolution, 7 (28%) required TEE imaging > 6 months after index TEE to show clearance of thrombus. Rates of LAT resolution were similar between patients who had alterations in OAC and those who did not (52 vs. 60%; P = 0.601). CONCLUSIONS After initial detection of left atrial thrombus despite uninterrupted anticoagulation for atrial fibrillation or flutter, > 40% patients have persistent clot despite additional extended anticoagulation.
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18
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Daaboul IS, Koroleva SY, Kudrjavtseva AA, Sokolova AA, Napalkov DA, Fomin VV. THROMBOSIS OF LEFT ATRIAL APPENDAGE DURING THERAPY WITH DIRECT ORAL ANTICOAGULANT. CLINICAL CASE. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2018. [DOI: 10.20996/1819-6446-2018-14-3-350-355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The article presents a clinical observation of the left atrial appendage thrombosis in a 51-year-old female patient with a paroxysmal form of nonvalvular atrial fibrillation which occurred despite long-term anticoagulant therapy with apixaban in a full dose (5 mg b.i.d.), and the patient’s management. The patient was admitted with recurrent symptomatic paroxysm for more than 48 hours, because of which, in accordance with the recommendations, transesophageal echocardiography was performed before an emergency rhythm restoration. Thrombus in the left atrial appendage 0.5×1.03 cm in size was detected. It was decided to refrain from the immediate restoration of the rhythm due to the very high risk of thromboembolic complications. In connection with the categorical refusal of the patient from warfarin, it was decided to replace apixaban with another direct oral anticoagulant – dabigatran 150 mg bid for a period of 4 weeks followed by performing a control transesophageal echocardiographic study. As a result, no thrombus was found on control echocardiography. The particularity of this observation is concomitant hypertrophic cardiomyopathy and diabetes mellitus type 1 in this patient.
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19
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Non-vitamin K antagonist oral anticoagulants for the treatment of intracardiac thrombosis. J Thromb Thrombolysis 2018; 46:332-338. [DOI: 10.1007/s11239-018-1693-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Zhan Y, Joza J, Al Rawahi M, Barbosa RS, Samuel M, Bernier M, Huynh T, Thanassoulis G, Essebag V. Assessment and Management of the Left Atrial Appendage Thrombus in Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2018; 34:252-261. [DOI: 10.1016/j.cjca.2017.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/04/2017] [Accepted: 12/11/2017] [Indexed: 01/14/2023] Open
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Comparison of prevalence and management of left atrial appendage thrombi under old and new anticoagulants prior to left atrial catheter ablation. Am Heart J 2017; 193:8-15. [PMID: 29129259 DOI: 10.1016/j.ahj.2017.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 07/31/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prevalence and management of left atrial appendage (LAA) thrombi associated with new anticoagulants remain to be elucidated, especially prior to atrial fibrillation (AFib) ablation. This study sought to (1) compare the prevalence of LAA thrombi and/or severe LAA contrast under vitamin K antagonist (VKA) agents and novel oral anticoagulants (NOACs), (2) evaluate the rate of LAA thrombus resolution after anticoagulation modification, and (3) determine the predictive factors of LAA thrombi and severe LAA contrast in patients prior to LA AFib ablation. METHODS Between January 2013 and March 2016, 576 consecutive patients referred for AFib ablation were included, and the prevalence of transesophageal echocardiography-detected thrombi was similar under NOACs (2.1%) and VKA agents (2.6%). RESULTS Thrombus resolution was obtained in 50% of cases following anticoagulation modification. Through multivariate exact logistic regression analysis with relevant clinical and echocardiographic features, age (P<.001), LAA hypocontractility (P<.001), and left ventricular ejection fraction (P=.007) were found to be independently associated with the occurrence of LAA thrombus. The relevant factors independently associated with LAA thrombus or severe contrast were LAA hypocontractility (P<.001) and age (P<.001). CONCLUSIONS The prevalence of transesophageal echocardiography-detected thrombi in patients referred for AFib ablation is similar under NOACs (2.1%) and VKA agents (2.6%). Under VKA therapy with 3-4 international normalized ratio, 50% of thrombi dissolved. Independent predictive factors of procedure contraindication included age, LAA hypocontractility, and left ventricular ejection fraction.
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22
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Orenes-Piñero E, Esteve-Pastor MA, Valdés M, Lip GY, Marín F. Efficacy of non-vitamin-K antagonist oral anticoagulants for intracardiac thrombi resolution in nonvalvular atrial fibrillation. Drug Discov Today 2017; 22:1565-1571. [DOI: 10.1016/j.drudis.2017.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 05/02/2017] [Accepted: 05/26/2017] [Indexed: 02/02/2023]
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Li Y, Lin J, Peng C. Resolution of massive left atrial appendage thrombi with rivaroxaban before balloon mitral commissurotomy in severe mitral stenosis: A case report and literature review. Medicine (Baltimore) 2016; 95:e5577. [PMID: 27930571 PMCID: PMC5266043 DOI: 10.1097/md.0000000000005577] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Data on nonvitamin K antagonist oral anticoagulant being used for the treatment of LAA thrombi are limited only in nonvalvular atrial fibrillation. There are no data on the antithrombotic efficacy and safety of nonvitamin K antagonist oral anticoagulant in the resolution of left atrial appendage (LAA) thrombi in patients with rheumatic mitral stenosis. PATIENT CONCERNS A 49-year-old woman with known rheumatic mitral stenosis and atrial fibrillation was referred for percutaneous transvenous mitral commissurotomy because of progressive dyspnea on exertion over a period of 3 months. DIAGNOSES Transesophageal echocardiography (TEE) demonstrated a large LAA thrombus protruding into left atria cavity before the procedure. INTERVENTIONS Direct factor Xa (FXa) inhibitor rivaroxaban (20 mg/d) was started for the patient. After 3 weeks of rivaroxaban treatment TEE showed a relevantly decreased thrombus size, and a complete thrombus resolution was achieved after 5 weeks of anticoagulant therapy with the FXa inhibitor. OUTCOMES To the best of our knowledge, this is the first documented case of large LAA thrombus resolution with nonvitamin K antagonist oral anticoagulant in severe mitral stenosis, and in which percutaneous transvenous mitral commissurotomy was performed subsequently. LESSONS The report indicated that rivaroxaban could be a therapeutic option for mitral stenosis patients with LAA thrombus. Further study is required before the routine use of rivaroxaban in patients with rheumatic mitral stenosis and atrial fibrillation.
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Saito S, Shindo S, Tsudaka S, Uchida K, Shirakawa M, Yoshimura S. Resolving Thrombus in the Left Atrial Appendage by Edoxaban Treatment after Acute Ischemic Stroke: Report of 2 Cases. J Stroke Cerebrovasc Dis 2016; 25:e188-91. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 07/20/2016] [Accepted: 07/24/2016] [Indexed: 11/27/2022] Open
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Marsico F, Cecere M, Parente A, Paolillo S, de Martino F, Dellegrottaglie S, Trimarco B, Perrone Filardi P. Effects of novel oral anticoagulants on left atrial and left atrial appendage thrombi: an appraisal. J Thromb Thrombolysis 2016; 43:139-148. [DOI: 10.1007/s11239-016-1421-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lip GYH, Hammerstingl C, Marin F, Cappato R, Meng IL, Kirsch B, van Eickels M, Cohen A. Left atrial thrombus resolution in atrial fibrillation or flutter: Results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J 2016; 178:126-34. [PMID: 27502860 DOI: 10.1016/j.ahj.2016.05.007] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 05/05/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Data on left atrial/left atrial appendage (LA/LAA) thrombus resolution after non-vitamin K antagonist (VKA) oral anticoagulant treatment are scarce. The primary objective of X-TRA was to explore the use of rivaroxaban for the resolution of LA/LAA thrombi in patients with nonvalvular atrial fibrillation (AF) or atrial flutter, with the CLOT-AF registry providing retrospective data after standard-of-care therapy in this setting. METHODS X-TRA was a prospective, single-arm, open-label, multicenter study that investigated rivaroxaban treatment for 6 weeks for LA/LAA thrombus resolution in patients with nonvalvular AF or atrial flutter and LA/LAA thrombus confirmed at baseline on a transesophageal echocardiogram (TEE). CLOT-AF retrospectively collected thrombus-related patient outcome data after standard-of-care anticoagulant treatment for 3 to 12 weeks in patients with nonvalvular AF or atrial flutter who had LA/LAA thrombi on TEE recorded in their medical file. RESULTS In X-TRA, patients were predominantly (95.0%) from Eastern European countries. The adjudicated thrombus resolution rate was 41.5% (22/53 modified intention-to-treat [mITT] patients, 95% CI 28.1%-55.9%) based on central TEE assessments. Resolved or reduced thrombus was evident in 60.4% (32/53 mITT patients, 95% CI 46.0%-73.6%) of patients. In CLOT-AF, the reported thrombus resolution rate was 62.5% (60/96 mITT patients, 95% CI 52.0%-72.2%) and appeared better in Western European countries (34/50; 68.0%) than in Eastern European countries (26/46; 56.5%). CONCLUSION X-TRA is the first prospective, multicenter study examining LA/LAA thrombus resolution with a non-VKA oral anticoagulant in VKA-naïve patients or in patients with suboptimal VKA therapy. Rivaroxaban could be a potential option for the treatment of LA/LAA thrombi.
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Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | | | | | - Bodo Kirsch
- Global Research and Development Statistics, Bayer Pharma AG, Berlin, Germany
| | | | - Ariel Cohen
- Cardiology Department, Assistance publique-Hôpitaux de Paris and université Pierre-et-Marie-Curie, Saint-Antoine University and Medical School, Paris, France
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Watanabe T, Shinoda Y, Ikeoka K, Inui H, Fukuoka H, Sunaga A, Kanda T, Uematsu M, Hoshida S. Dabigatran exhibits low intensity of left atrial spontaneous echo contrast in patients with nonvalvular atrial fibrillation as compared with warfarin. Heart Vessels 2016; 32:326-332. [PMID: 27406344 PMCID: PMC5334411 DOI: 10.1007/s00380-016-0871-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 07/01/2016] [Indexed: 11/29/2022]
Abstract
The presence of spontaneous echo contrast (SEC) in the left atrium has been reported to be an independent predictor of thromboembolic risk in patients with atrial fibrillation (AF). Dabigatran was associated with lower rates of stroke and systemic embolism as compared with warfarin when administered at a higher dose. Between July 2011 and October 2015, nonvalvular AF patients treated with warfarin or dabigatran who had transesophageal echocardiography prior to ablation therapy for AF were enrolled. The intensity of SEC was classified into four grades, from 0 to 3. Univariate and multivariate analysis was performed to analyze factors associated with SEC. Sixty-five patients were on dabigatran and 65 were on warfarin, with the prothrombin time in therapeutic range. There were no significant differences in the age, CHADS2 score, left atrial dimension, and left atrial appendage flow between the two groups. However, there were more grade 2 or higher patients with left atrial SEC in the warfarin group (n = 20) than in the dabigatran group (n = 2) (p < 0.001). When multivariate regression analysis was performed, grade 2 or higher left atrial SEC was independently associated with no dabigatran usage in addition to high brain natriuretic peptide level and high incidence of diabetes mellitus or persistent AF. Thus, dabigatran exhibited low intensity of left atrial SEC in nonvalvular AF patients as compared with warfarin.
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Affiliation(s)
- Tetsuya Watanabe
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan.
| | - Yukinori Shinoda
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Kuniyasu Ikeoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Hirooki Inui
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Hidetada Fukuoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Akihiro Sunaga
- Cardiovascular Center, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-8511, Japan
| | - Takashi Kanda
- Cardiovascular Center, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-8511, Japan
| | - Masaaki Uematsu
- Cardiovascular Center, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-8511, Japan
| | - Shiro Hoshida
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
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Patti G, Pengo V, Marcucci R, Cirillo P, Renda G, Santilli F, Calabrò P, De Caterina AR, Cavallari I, Ricottini E, Parato VM, Zoppellaro G, Di Gioia G, Sedati P, Cicchitti V, Davì G, Golia E, Pariggiano I, Simeone P, Abbate R, Prisco D, Zimarino M, Sofi F, Andreotti F, De Caterina R. The left atrial appendage: from embryology to prevention of thromboembolism. Eur Heart J 2016; 38:877-887. [DOI: 10.1093/eurheartj/ehw159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/26/2016] [Indexed: 12/13/2022] Open
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Akiyama H, Hoshino M, Shimizu T, Hasegawa Y. Resolution of Internal Carotid Arterial Thrombus by the Thrombolytic Action of Dabigatran: A first case report. Medicine (Baltimore) 2016; 95:e3215. [PMID: 27057852 PMCID: PMC4998768 DOI: 10.1097/md.0000000000003215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) have been reported to cause resolution of intracardiac thrombus, but there have been no reported cases of internal carotid arterial thrombus resolution.We report a case of a 76-year-old man in whom an internal carotid arterial thrombus resolved after administration of the NOAC dabigatran at a dose of 110 mg twice daily.This is the first reported case of carotid arterial thrombus resolution after oral intake of NOAC (direct thrombin and factor Xa inhibitors), to the best of our knowledge.We conclude that this case had major clinical significance because it might represent one of the multiple effects of NOACs.
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Affiliation(s)
- Hisanao Akiyama
- From the Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan (HA, MH, TS, YH)
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30
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Frenkel D, D'Amato SA, Al-Kazaz M, Markowitz SM, Liu CF, Thomas G, Ip JE, Sharma SK, Yang H, Singh P, Lerman BB, Cheung JW. Prevalence of Left Atrial Thrombus Detection by Transesophageal Echocardiography: A Comparison of Continuous Non-Vitamin K Antagonist Oral Anticoagulant Versus Warfarin Therapy in Patients Undergoing Catheter Ablation for Atrial Fibrillation. JACC Clin Electrophysiol 2016; 2:295-303. [PMID: 29766887 DOI: 10.1016/j.jacep.2016.01.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/02/2015] [Accepted: 01/07/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The purpose of this study is to determine whether patients on ≥4 weeks of continuous non-vitamin K antagonist oral anticoagulant (NOAC) therapy require transesophageal echocardiography (TEE) before catheter ablation of atrial fibrillation (AF) or atrial flutter and to compare rates of left atrial (LA) thrombus and dense spontaneous echocardiographic contrast (SEC) in patients on NOAC versus warfarin therapy. BACKGROUND The impact of NOAC therapy on the rates of LA thrombus detection by TEE in patients undergoing catheter ablation of AF is unknown. METHODS Initial TEEs for 388 patients (median age, 65 years; 74% male) on ≥4 weeks of continuous NOAC (n = 183) or warfarin therapy (n = 205) undergoing catheter ablation of AF and flutter were reviewed. RESULTS After ≥4 weeks of therapy, the prevalence of LA thrombus and LA thrombus/dense SEC among patients on NOACs was 4.4% and 6.0%, respectively, which was comparable with that of patients on warfarin. LA thrombus rates among patients on dabigatran, rivaroxaban, and apixaban were 5.4%, 4.8%, and 0%, respectively (p = 0.46). Predictors of LA thrombus were congestive heart failure (odds ratio [OR]: 5.38; 95% confidence interval [CI]: 1.79 to 16.2; p = 0.003); and persistent AF (OR: 3.27; 95% CI: 1.06 to 10.2; p = 0.040). CONCLUSIONS Despite ≥4 weeks of anticoagulation, the rate of LA thrombus in patients on NOACs before catheter ablation of AF or atrial flutter was 4.4%. This suggests that continuous NOAC therapy does not eliminate the need for TEE before catheter ablation of AF.
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Affiliation(s)
- Daniel Frenkel
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Salvatore A D'Amato
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Mohamed Al-Kazaz
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Steven M Markowitz
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Christopher F Liu
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - George Thomas
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - James E Ip
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Sandeep K Sharma
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Hua Yang
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Parmanand Singh
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Bruce B Lerman
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Jim W Cheung
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA.
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Resolution of a warfarin and dabigatran-resistant left atrial appendage thrombus with apixaban. J Arrhythm 2016; 32:233-5. [PMID: 27354873 PMCID: PMC4913128 DOI: 10.1016/j.joa.2016.01.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/11/2016] [Accepted: 02/01/2016] [Indexed: 12/29/2022] Open
Abstract
The majority of embolisms associated with atrial fibrillation (AF) are from the left atrial appendage (LAA). To treat the existing thrombus, warfarin and novel anticoagulants have been used. However, there has been no clinical information regarding the difference of the effects of congealing the fibrinogenolysis system among these oral anticoagulants. Here, we report a case of persistent AF, in whom apixaban, factor Xa inhibitor resolved an LAA clot refractory to warfarin and direct thrombin inhibition. Factor Xa inhibitor, apixaban, could resolve the left appendage thrombosis refractory to warfarin and dabigatran.
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32
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Vestito D, Desantis D, Colonna P. Three-dimensional Transesophageal Echocardiography Demonstration of Left Atrial Appendage Echocontrast Regression after 6 Months Therapy with Dabigatran and not with Warfarin. J Cardiovasc Echogr 2016; 26:52-55. [PMID: 28465961 PMCID: PMC5224660 DOI: 10.4103/2211-4122.183751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
While warfarin therapy is efficacious in treating left atrial (LA) thrombus formation in patients with nonvalvular atrial fibrillation (AF), it does not affect red cell aggregation in vitro or LA spontaneous echo-contrast in patients. In this patient with left ventricular (LV) dysfunction secondary to AF, we observed the disappearance of dense echo-contrast in the atrial appendage after therapy with dabigatran and not with well-controlled warfarin. This allowed us to analyze accurately the appendage with three-dimensional (3D) transesophageal echocardiography (TEE) excluding thrombi and to perform electrical cardioversion to obtain a significant improvement of LV function. This case demonstrates the capability of dabigatran and not of warfarin in reducing the intense spontaneous echocontrast in atrial appendage and the ability of 3D TEE in analyzing accurately the appendage, excluding thrombi to safely perform cardioversion.
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Affiliation(s)
| | - Delia Desantis
- Department of Cardiology, Hospital Policlinico, Bari, Italy
| | - Paolo Colonna
- Department of Cardiology, Hospital Policlinico, Bari, Italy
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33
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Chung K, Paek YM, Lee HJ, Hong KS. Dabigatran Effect on Left Ventricular Thrombus in a Patient with Acute Ischemic Stroke. J Stroke 2015; 17:366-8. [PMID: 26438004 PMCID: PMC4635718 DOI: 10.5853/jos.2015.17.3.366] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/07/2015] [Accepted: 08/10/2015] [Indexed: 01/23/2023] Open
Affiliation(s)
- Kyuyoon Chung
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Young Min Paek
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hye Jung Lee
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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Ferner M, Wachtlin D, Konrad T, Deuster O, Meinertz T, von Bardeleben S, Münzel T, Seibert-Grafe M, Breithardt G, Rostock T. Rationale and design of the RE-LATED AF—AFNET 7 trial: REsolution of Left atrial-Appendage Thrombus—Effects of Dabigatran in patients with Atrial Fibrillation. Clin Res Cardiol 2015; 105:29-36. [DOI: 10.1007/s00392-015-0883-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 06/09/2015] [Indexed: 11/30/2022]
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35
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Lip GYH, Hammerstingl C, Marin F, Cappato R, Meng IL, Kirsch B, Morandi E, van Eickels M, Cohen A. Rationale and design of a study exploring the efficacy of once-daily oral rivaroxaban (X-TRA) on the outcome of left atrial/left atrial appendage thrombus in nonvalvular atrial fibrillation or atrial flutter and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J 2015; 169:464-71.e2. [PMID: 25819852 DOI: 10.1016/j.ahj.2014.12.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/04/2014] [Indexed: 12/24/2022]
Abstract
There are still many unresolved issues concerning patient outcomes and prognostic factors in patients with atrial fibrillation (AF) and left atrial/left atrial appendage (LA/LAA) thrombi. Rivaroxaban (Xarelto®), a potent and highly selective oral, direct factor Xa inhibitor, is a new therapeutic option in this setting. The planned study program will consist of a prospective interventional study (X-TRA) and a retrospective observational registry (CLOT-AF). The primary objective of the X-TRA study is to explore the efficacy of rivaroxaban in the treatment of LA/LAA thrombi in patients with nonvalvular AF or atrial flutter, scheduled to undergo cardioversion or AF ablation, in whom an LA/LAA thrombus has been found on transesophageal echocardiography (TEE) before the procedure. The primary end point is the complete LA/LAA thrombus resolution rate at 6 weeks of end of treatment confirmed by TEE. The secondary objectives are to describe categories of thrombus outcome in patients (resolved, reduced, unchanged, larger, or new) confirmed on TEE at the end of treatment (after 6 weeks of treatment), incidence of the composite of stroke and noncentral nervous system systemic embolism at the end of treatment and during follow-up, and incidence of all bleeding at the end of treatment and during follow-up. The objective of the CLOT-AF registry is to provide retrospective thrombus-related patient outcome data after standard-of-care anticoagulant treatment in patients with nonvalvular AF or atrial flutter, who have TEE-documented LA/LAA thrombi. The data will be used as a reference for the prospective X-TRA study. In conclusion, X-TRA and CLOT-AF will provide some answers to the many unresolved issues concerning patient outcomes and prognostic factors in patients with AF and LAA thrombi. Results from this study program would provide the first prospective interventional study (X-TRA) and a large international retrospective observational registry (CLOT-AF) on the prevalence and natural history of LA/LAA thrombi. Unique data on clot resolution with rivaroxaban in a prospective cohort would be obtained in X-TRA.
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Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
| | | | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | - Riccardo Cappato
- Arrhythmia and Electrophysiology Center, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Bodo Kirsch
- Global Research and Development Statistics, Bayer HealthCare, Berlin, Germany
| | - Eolo Morandi
- Therapeutic Cardiovascular and Coagulation, Global Development, Bayer HealthCare, São Paulo, Brazil
| | | | - Ariel Cohen
- Cardiology Department, Assistance Publique-Hôpitaux de Paris and Université Pierre-et-Marie-Curie, Saint-Antoine University and Medical School, Paris, France
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36
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Thrombus formation in left atrium on dabigatran therapy. Case Rep Cardiol 2015; 2015:518982. [PMID: 25793127 PMCID: PMC4352418 DOI: 10.1155/2015/518982] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 11/18/2022] Open
Abstract
Dabigatran is a direct thrombin inhibitor, approved in the United States for stroke prevention in nonvalvular atrial fibrillation and prevention and treatment of thromboembolism. It has been also used in patients with documented left atrial thrombus, where treatment with dabigatran effectively led to thrombus resolution. We present a rare case of left atrial thrombus formation in a patient with chronic atrial fibrillation being treated with dabigatran 150 mg twice a day. The patient presented with multiple embolic strokes. There are only three such cases reported in the literature till date, all of whom had thrombus in the left atrium. The possible mechanisms of dabigatran failure include compensatory increase in upstream coagulation factors due to single level downstream blockade of thrombin, lack of inhibition of all available thrombin, and lack of monitoring measures that can be implemented in common clinical laboratories that lead to failure to assess adherence, which in turn can lead to dabigatran failure.
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37
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Mitamura H, Nagai T, Watanabe A, Takatsuki S, Okumura K. Left atrial thrombus formation and resolution during dabigatran therapy: A Japanese Heart Rhythm Society report. J Arrhythm 2015; 31:226-31. [PMID: 26336564 DOI: 10.1016/j.joa.2014.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/22/2014] [Accepted: 12/26/2014] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Protocols on the use of novel oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) undergoing electrical cardioversion (ECV) are lacking. AIM The study was aimed at evaluating the efficacy of dabigatran (Dabi) treatment in preventing peri-ECV stroke. METHODS A retrospective survey of the incidence and fate of left atrial (LA) thrombus during Dabi therapy in patients with AF was conducted between December 2012 and January 2013 by the Japanese Heart Rhythm Society. RESULTS A total of 198 patients from 299 institutions underwent transesophageal echocardiography (TEE) to rule out LA thrombus before ECV. Of these, LA thrombus was found in eight patients (4%), who tended to be older (67.3 vs. 61.3 years, p=0.175), had higher CHADS2 scores (1.88 vs. 0.95, p=0.058), and a higher prevalence of prior stroke or transient ischemic attack (22.2% vs. 2.6%, p=0.034) than those without LA thrombus. Of the eight patients with LA thrombus, one had LA thrombus during a Dabi 150 mg b.i.d treatment, whereas the remaining seven were receiving 110 mg b.i.d for 3 weeks or longer. In 6 of the 8 patients with LA thrombus, a second TEE was performed, revealing complete resolution of LA thrombus in five; among these five patients, one received Dabi dosage of 150 mg b.i.d unchanged, two received an increased dosage from 110 mg to 150 mg b.i.d, and two were switched to warfarin. Two patients had a stroke 3 and 15 days after ECV, and one had a major large intestine bleeding episode during Dabi therapy. CONCLUSIONS LA thrombus developed in 4% of patients with AF receiving Dabi. Older patients with a higher CHADS2 score receiving a lower Dabi dosage were more likely to develop LA thrombus, which was resolved with a prolonged or increased dosage. A higher Dabi dosage may be more beneficial before ECV but prospective randomized studies would be needed to confirm these results.
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Affiliation(s)
- Hideo Mitamura
- Cardiovascular Center, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, 4-2-22 Nishikicho, Tachikawa, Tokyo, Japan
| | - Takayuki Nagai
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | | | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Ken Okumura
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan
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38
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Kawano H, Kohno Y, Izumida S, Tsuneto A, Fukae S, Takeno M, Koide Y, Maemura K. Rivaroxaban therapy resulting in the resolution of right atrial thrombosis resistant to ordinary control with warfarin in a patient with atrial fibrillation. Intern Med 2015; 54:601-4. [PMID: 25786449 DOI: 10.2169/internalmedicine.54.3003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 72-year-old man with non-valvular atrial fibrillation and metastatic liver and lung cancer after surgery for colon cancer developed thrombosis in the right atrium one month after decreasing the dose of warfarin due to the introduction of double anti-platelet therapy for coronary stent implantation. Restoring the warfarin dose with ordinary control for two months did not result in any changes in the size of the thrombus; however, the subsequent substitution of rivaroxaban (oral treatment with a direct Factor Xa inhibitor) for warfarin ultimately resolved the thrombosis.
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Affiliation(s)
- Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
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39
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Fujii S. Editorial: Resolution of left atrial thrombus with novel oral anticoagulants. J Cardiol Cases 2014; 10:241-242. [PMID: 30534253 PMCID: PMC6279654 DOI: 10.1016/j.jccase.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Indexed: 11/17/2022] Open
Affiliation(s)
- Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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40
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Resolution of left ventricular thrombus secondary to tachycardia-induced heart failure with rivaroxaban. Case Rep Med 2014; 2014:814524. [PMID: 25477972 PMCID: PMC4247908 DOI: 10.1155/2014/814524] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/29/2014] [Accepted: 10/30/2014] [Indexed: 11/25/2022] Open
Abstract
A 42-year-old man was admitted to our hospital because of lumbago and tachycardia-induced heart failure. Transthoracic echocardiography revealed impaired left ventricular function and a ball mass of thrombus in the left ventricle (LV). He was found to have systemic embolism in the spleen, kidneys, brain, and limbs. The patient was treated with limb thrombectomy followed by anticoagulation. Seven days after the direct factor Xa inhibitor, rivaroxaban, was initiated, transthoracic echocardiography was repeated, revealing disappearance of the LV thrombus without any clinical signs of cardiogenic embolism. His heart failure responded well and the LV wall motion had improved. This case suggests rivaroxaban has fibrinolytic effects on thrombi even in the LV.
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41
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Kato T, Yasaka M, Yabuki T, Adachi T, Toyoda S, Inoue T. Two-week administration of rivaroxaban resolved left atrial thrombus. J Cardiol Cases 2014; 10:238-240. [PMID: 30534252 DOI: 10.1016/j.jccase.2014.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 08/06/2014] [Accepted: 08/22/2014] [Indexed: 11/19/2022] Open
Abstract
An 89-year-old man visited our hospital complaining of palpitation. Electrocardiography showed atrial fibrillation, and transthoracic echocardiography demonstrated a mobile thrombus of 28.6 mm × 20.8 mm in the left atrium. Administration of a direct factor Xa inhibitor rivaroxaban (10 mg/day) was started. The thrombus reduced its size and disappeared completely 2 weeks after the commencement of rivaroxaban treatment. To our knowledge, this is the first case report that rivaroxaban successfully dissolved left atrial thrombus during a short period. Rivaroxaban might have a potential, not only to prevent de novo thrombus formation, but also to dissolve established thrombi by direct inhibition of free and thrombus-associated factor Xa. <Learning objective: The incidence of nonvalvular atrial fibrillation is increasing, and left atrial thrombus is the major cause of cardiogenic thrombo-embolism that we need to prevent. Recently, novel oral anticoagulants have been developed. The effects of these agents on intracardiac thrombus resolution have not been fully elucidated. Data from a large cohort study would be required to assess efficacy of novel oral anticoagulants for thrombus resolution.>.
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Affiliation(s)
- Toru Kato
- Department of Clinical Research, National Hospital Organization Tochigi Medical Center, Tochigi, Japan
- Department of Cardiovascular Disease, Dokkyo Medical University, Tochigi, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Taku Yabuki
- Department of Internal Medicine, National Hospital Organization Tochigi Medical Center, Tochigi, Japan
| | - Taichi Adachi
- Department of Cardiovascular Medicine, National Hospital Organization Tochigi Medical Center, Tochigi, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Disease, Dokkyo Medical University, Tochigi, Japan
| | - Teruo Inoue
- Department of Cardiovascular Disease, Dokkyo Medical University, Tochigi, Japan
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42
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Saito S, Tomita H, Kimura Y, Shiroto H, Hagii J, Metoki N, Hitomi H, Kamada T, Osanai T, Okumura K, Yasujima M. Reduced Smoke-like Echo and Resolved Thrombus in the Left Atrium with Rivaroxaban Therapy in an Acute Cardioembolic Stroke Patient. J Stroke Cerebrovasc Dis 2014; 23:1747-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 11/15/2022] Open
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43
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Dobashi S, Fujino T, Ikeda T. Use of apixaban for an elderly patient with left atrial thrombus. BMJ Case Rep 2014; 2014:bcr-2014-203870. [PMID: 24962484 DOI: 10.1136/bcr-2014-203870] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
An 86-year-old man had long-standing persistent atrial fibrillation, but had not received any anticoagulants. Transthoracic echocardiography revealed a large thrombus formation in the left atrium. We hesitated to use the conventional anticoagulant, warfarin, because he was very old and had dementia. We decided to resolve the thrombus at our outpatient clinic. He was started on the novel oral anticoagulant, apixaban, 2.5 mg twice daily, which is a direct factor Xa (FXa) inhibitor. After 11 weeks on that therapy, the thrombus formation had almost resolved. During oral anticoagulant therapy, no serious bleeding complications, systemic embolisms or strokes were noted. To the best of our knowledge, we are the first to report that apixaban (5 mg/day) can possibly resolve a thrombus formation in the left atrium.
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Affiliation(s)
- Shintaro Dobashi
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
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44
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The Antithrombotic Effect of Dabigatran. Can J Cardiol 2014; 30:248.e1-2. [DOI: 10.1016/j.cjca.2013.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 09/24/2013] [Accepted: 09/24/2013] [Indexed: 11/19/2022] Open
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45
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Kawakami T, Kobayakawa H, Ohno H, Tanaka N, Ishihara H. Resolution of left atrial appendage thrombus with apixaban. Thromb J 2013; 11:26. [PMID: 24359320 PMCID: PMC3878218 DOI: 10.1186/1477-9560-11-26] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 11/17/2013] [Indexed: 01/28/2023] Open
Abstract
Left atrial appendage (LAA) thrombosis is an important cause of cardiogenic cerebral thromboembolism. Apixaban is a member of the class of novel oral anticoagulants (NOAC) and is superior to warfarin in preventing stroke or systemic embolism, causes less bleeding, and results in lower mortality in patients with atrial fibrillation. There are few reports of resolution of LAA thrombus with other NOAC. We present a 72-year-old male patient with persistent atrial fibrillation associated with left atrial thrombus. Sixteen days of apixaban treatment showed complete thrombus resolution. In this study, soluble fibrin and D-dimer levels decreased without prolongation of international normalized ratio (INR) and activated partial thromboplastin time (APTT).
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Affiliation(s)
- Tohru Kawakami
- From the Division of Cardiology, Ichinomiyanishi Hospital, 1 Kaimei-hira, Ichinomiya, Aichi, Japan.
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Kaku B. Intra-cardiac thrombus resolution after anti-coagulation therapy with dabigatran in a patient with mid-ventricular obstructive hypertrophic cardiomyopathy: a case report. J Med Case Rep 2013; 7:238. [PMID: 24103078 PMCID: PMC3851832 DOI: 10.1186/1752-1947-7-238] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 08/29/2013] [Indexed: 11/12/2022] Open
Abstract
Introduction Although dabigatran, a novel oral anti-coagulant, has been approved for the prevention of thromboembolism in patients with non-valvular atrial fibrillation, the efficacy of dabigatran for the resolution of established intra-cardiac thrombi has not been validated. Herein is describe a case in which dabigatran was effective for thrombus resolution in a patient with a left ventricular aneurysm. Case presentation A 59-year-old Japanese man with a mid-ventricular obstructive hypertrophic cardiomyopathy-associated apical aneurysm presented with a left ventricular apical thrombus (15.0mm×17.0mm). Anti-coagulation therapy with dabigatran (150mg b.i.d. with meals) was initiated. Following dabigatran administration, weekly echocardiographic examinations demonstrated gradual decreases in thrombus size. After three weeks, no thrombus was detected and no systemic thromboembolic events had occurred. Conclusions The left ventricular apical thrombus resolved after dabigatran administration. Hence, dabigatran may represent an alternative to warfarin as a therapeutic option in patients with previously detected intra-cardiac thrombus.
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Affiliation(s)
- Bunji Kaku
- Division of Cardiovascular Medicine, Toyama Red Cross Hospital, 2-1-58 Ushijima-honmachi, Toyama, Japan.
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Tabata E, Yasaka M, Wakugawa Y, Komori M, Mori K, Tsurusaki Y, Kokuba K, Sambongi Y, Maeda K, Okada Y. Increase in the Size of an Intracardiac Thrombus during Dabigatran Therapy (110 mg b.i.d.) in an Acute Cardioembolic Stroke Patient. Cerebrovasc Dis Extra 2013; 3:78-80. [PMID: 23687505 PMCID: PMC3656689 DOI: 10.1159/000351137] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
We report a case of atrial fibrillation in a patient in whom a mobile thrombus in the left atrial appendage increased in size after low-dose dabigatran therapy. A 74-year-old man was admitted to our hospital because of sudden onset of right hemiplasia and dysarthria. On admission, his National Institutes of Health Stroke Scale score was three. Axial diffusion-weighted magnetic resonance images and magnetic resonance angiography images showed hyperintense signals in the left front-parietal cerebral cortex without any intracranial stenotic lesions, and acute cardioembolic stroke associated with nonvalvular atrial fibrillation was diagnosed. Transesophageal echocardiography revealed a mobile thrombosis (1.0 × 2.2 cm) in the left atrial appendage, and dabigatran therapy (110 mg b.i.d.) was initiated to prevent stroke recurrence. Transesophageal echocardiography performed 6 days later revealed that the size of the thrombus had increased to 1.5 × 3.0 cm. Medication was changed to warfarin, and the thrombosis subsequently decreased in size. The patient did not have a recurrent stroke and was discharged with a National Institutes of Health Stroke Scale score of zero. This case demonstrates that low-dose dabigatran may not be effective in reducing the size of a thrombus.
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Affiliation(s)
- Emi Tabata
- Department of Cerebrovascular Medicine and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukukuoka, Japan
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Kis Z, Földesi C, Pál M, Som Z, Csillik A, Abrahám P, Temesvári A, Fontos G, Szatmári A, Andréka P, Kardos A. [Percutaneous left atrial appendage closure after resolution of left atrial appendage thrombi with dabigatran]. Orv Hetil 2013; 154:262-5. [PMID: 23395790 DOI: 10.1556/oh.2013.29550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The "gold standard" of the prevention of atrial fibrillation related thromboembolic events is anticoagulation therapy with oral vitamin K antagonists. A certain proportion of high-risk patients with atrial fibrillation are not receiving effective antithrombotic therapy because of problems associated with its use. Resolution of subsequent left atrial appendage thrombi is quite a great challenge in patients who are not tolerating "standard" antithrombotic drugs. According to the knowledge of the authors, this is the first report of a patient with non-valvular persistent atrial fibrillation and high stroke risk, who was intolerant to "standard" anticoagulant therapy and had persistent left atrial appendage thrombi following the use of a wide variety of "standard" anticoagulants. Successful resolution of left atrial appendage thrombi with dabigatran and successful percutaneous left atrial appendage closure were performed in this case.
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Affiliation(s)
- Zsuzsanna Kis
- Gottsegen György Országos Kardiológiai Intézet Felnőtt Kardiológia Budapest.
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