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Cui J, Xia SJ, Tang RB, He L, Guo XY, Li SN, Liu N, Sang CH, Long DY, Du X, Dong JZ, Ma CS. Morphology and location of thrombus and sludge in patients with non-valvular atrial fibrillation. BMC Cardiovasc Disord 2024; 24:398. [PMID: 39085776 PMCID: PMC11290267 DOI: 10.1186/s12872-024-04073-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Stroke and thromboembolism in nonvalvular atrial fibrillation (NVAF) primarily arise from thrombi or sludge in the left atrial appendage (LAA). Comprehensive insight into the characteristics of these formations is essential for effective risk assessment and management. METHODS We conducted a single-center retrospective observational of 176 consecutive NVAF patients with confirmed atrial/appendage thrombus or sludge determined by a pre-ablation transesophageal echocardiogram (TEE) from December 2017 to April 2019. We obtained clinical and echocardiographic characteristics, including left atrial appendage emptying velocity (LAAeV) and filling velocity (LAAfV). Data analysis focused on identifying the morphology and location of thrombus or sludge. Patients were divided into the solid thrombus and sludge groups, and the correlation between clinical and echocardiographic variables and thrombotic status was analyzed. RESULTS Morphological classification: In total, thrombi were identified in 78 patients, including 71 (40.3%) mass and 7 (4.0%) lamellar, while sludge was noted in 98 (55.7%). Location classification: 92.3% (72/78) of patients had thrombus confined to the LAA; 3.8% (3/78) had both LA and LAA involvement; 2.7% (2/78) had LA, LAA and RAA extended into the RA, the remained 1.2%(1/78) was isolated to RAA. 98.0% (96/98) of patients had sludge confined to the LAA; the remaining 2.0% (2/98) were present in the atrial septal aneurysm, which protrusion of interatrial septum into the RA. The thrombus and sludge groups showed low LAAeV (19.43 ± 9.59 cm/s) or LAAfV (17.40 ± 10.09 cm/s). Only LA dimension ≥ 40 mm was independently associated with the thrombus state in the multivariable model. CONCLUSION This cohort study identified rare thrombus morphology and systematically summarized the classification of thrombus morphology. The distribution of thrombus and sludge outside limited to LAA was updated, including bilateral atrial and appendage involvement and rare atrial septal aneurysm sludge. LAAeV and LAAfV were of limited value in distinguishing solid thrombus from sludge. CLINICAL TRIAL NUMBER ChiCTR-OCH-13,003,729.
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Affiliation(s)
- Jing Cui
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Shi-Jun Xia
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Liu He
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Xue-Yuan Guo
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Song-Nan Li
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Nian Liu
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - De-Yong Long
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Xin Du
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing, Zip, 100029, PR China.
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Katic J, Borovac JA. Treatment of Persistent Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation on Adequate Oral Anticoagulation: Pathways of Care for All-comers and Heart Failure Patients. Card Fail Rev 2023; 9:e05. [PMID: 37397240 PMCID: PMC10311400 DOI: 10.15420/cfr.2022.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/27/2023] [Indexed: 07/04/2023] Open
Abstract
In patients with AF, the presence of left atrial/left atrial appendage (LA/LAA) thrombus is related to an increased risk of thromboembolic events. Anticoagulation therapy, either with vitamin K antagonists or novel oral anticoagulants (NOACs) is therefore mandatory in AF with LA/LAA thrombus in order to lower the risk of stroke or other systemic embolic events. Despite the efficacy of these treatments, some patients will have persistent LAA thrombus remaining or may have contraindications to oral anticoagulation. Currently, little is known about the occurrence, risk factors and resolution rate of LA/LAA thrombus in patients who are already under optimal chronic oral anticoagulation, including vitamin K antagonists or NOACs. The common action in clinical practice in this scenario is switching from one to another anticoagulant drug exhibiting a different mechanism of action. Repeated cardiac imaging is then advised within several weeks to visually verify thrombus dissolution. Finally, there is a substantial scarcity of data on the role and optimal use of NOACs after LAA occlusion. The aim of this review is to critically evaluate data and provide up-to-date information on the best antithrombotic strategies in this challenging clinical scenario.
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Affiliation(s)
- Josip Katic
- Cardiovascular Diseases Department, University Hospital of Split Split, Croatia
| | - Josip Andelo Borovac
- Cardiovascular Diseases Department, University Hospital of Split Split, Croatia
- Department of Pathophysiology, University of Split School of Medicine Split, Croatia
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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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Prevalence and Rate of Resolution of Left Atrial Thrombus in Patients with Non-Valvular Atrial Fibrillation: A Two-Center Retrospective Real-World Study. J Clin Med 2022; 11:jcm11061520. [PMID: 35329845 PMCID: PMC8948620 DOI: 10.3390/jcm11061520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background and aim. Thromboembolic events due to left atrial appendage (LAA) thrombosis are the main complication of non-valvular atrial fibrillation (NVAF). Although anticoagulants are effective in patients with NVAF, a minimal residual thromboembolic risk persists. Little is known about the prevalence of LAA thrombus and the rate of resolution after the recommended period of anticoagulation therapy, including vitamin K antagonists (VKA), heparin, and non-vitamin K antagonist oral anticoagulants (NOACs). Methods and results. We aimed to study the prevalence of LAA thrombus in an unselected cohort of patients undergoing transesophageal echocardiogram (TEE), and the determinants of LAA thrombus resolution. We retrospectively analyzed 8888 consecutive TEEs performed over five years in two high-volume centers and included all patients with LAA thrombus. A total of 265 patients (3%) had an LAA thrombus. Among these, 97% presented with AF. Fifty-eight percent of patients were on anticoagulants at least three weeks before the diagnosis. After the LAA thrombus diagnosis, VKAs were prescribed in 52%, heparin in 18.5%, and NOAC in 27% of patients. Among the 183 patients with repeat TEE, performed at (25–75th) 39 days (21–84), 67% showed resolution of the LAA thrombus. Although the rate of thrombus resolution was higher in patients treated with NOACs (NOACs 71%, VKA 66%, Heparin 60%) the difference between anticoagulants was statistically non-significant (VKA, OR 0.9, p = 0.83; NOAC, OR 1.23, p = 0.42; heparin, OR 0.69, p = 0.35). Thus, NOACs were demonstrated to be at least as effective as other anticoagulants in the rate of LAA thrombus resolution. Upon multivariate-adjusted analysis, higher LAA emptying velocities were the only predictor of thrombus resolution. In conclusion, the majority of patients were already on anticoagulants. NOACs could be at least as effective as other anticoagulants, yielding an LAA thrombus resolution in two-thirds of patients. This may have clinical relevance, especially in patients undergoing cardioversion or catheter ablation.
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Watanabe T, Tachibana K, Shinoda Y, Minamisaka T, Fukuoka H, Inui H, Ueno K, Inoue S, Mine K, Hoshida S. Difference in left atrial D-dimer level in patients with atrial fibrillation treated with direct oral anticoagulant. BMC Cardiovasc Disord 2021; 21:487. [PMID: 34627142 PMCID: PMC8502280 DOI: 10.1186/s12872-021-02285-y] [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: 08/01/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background Atrial fibrillation (AF) may cause cerebral and systemic embolism. An increased D-dimer level indicates hyperactivation of secondary fibrinolysis, resulting in predilection for thrombosis. To clarify the differential effects of anticoagulation therapy, we compared the D-dimer levels in peripheral and left atrial (LA) blood of atrial fibrillation patients scheduled for ablation. Methods We analyzed 141 patients with non-valvular AF (dabigatran, n = 30; apixaban, n = 47; edoxaban, n = 64; mean age: 68 years, male: 60%). Peripheral venous blood and LA blood was collected before pulmonary vein isolation. We examined the laboratory and echocardiographic parameters. Results After adjusting for baseline characteristics, D-dimer level in the LA was significantly higher in patients treated with edoxaban than that in those on apixaban (0.77 ± 0.05 vs. 0.60 ± 0.05 μg/mL, P = 0.047), although there were no significant differences in peripheral D-dimer levels. We classified the D-dimer value of the LA into a normal group (< 0.9) and a high value group (≥ 1.0); the peripheral prothrombin fragment F1 + 2 level (odds ratio [OR] 1.012; 95% confidence interval [CI]: 1.003–1.022; P = 0.008) and left ventricular ejection fraction (LVEF) (OR, 0.947; 95% CI, 0.910–0.986; P = 0.008) were potential predictors of high LA D-dimer levels. Conclusions In apixaban-treated patients, the D-dimer level in the left atrium was lower than in edoxaban-treated patients on the day of ablation, suggesting that the anticoagulant effect of apixaban on the left atrium is better than that of edoxaban in patients with AF.
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Affiliation(s)
- Tetsuya Watanabe
- Division of Cardiology, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
| | - Koichi Tachibana
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Yukinori Shinoda
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Tomoko Minamisaka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Hidetada Fukuoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Hirooki Inui
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Keisuke Ueno
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Souki Inoue
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Kentaro Mine
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Shiro Hoshida
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
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Farkowski MM, Jubele K, Marín F, Gandjbakhch E, Ptaszynski P, Merino JL, Lenarczyk R, Potpara TS. Diagnosis and management of left atrial appendage thrombus in patients with atrial fibrillation undergoing cardioversion or percutaneous left atrial procedures: results of the European Heart Rhythm Association survey. Europace 2021; 22:162-169. [PMID: 31501852 DOI: 10.1093/europace/euz257] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
Practices regarding indications and timing for transoesophageal echocardiography (TOE) before cardioversion (CV) of atrial fibrillation (AF) or left atrial (LA) interventional procedures, and preferred imaging techniques and pharmacotherapy, in cases of thrombus resistant to chronic oral anticoagulation (OAC) treatment, are largely unknown. The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice in those areas of AF care. A 22-item online questionnaire was developed and distributed among the EHRA electrophysiology research network centres. The survey contained questions regarding indications, type and timing of imaging before CV or LA procedures and management of LA appendage (LAA) thrombus with special emphasis on thrombus resistant to OAC. Of 54 responding centres 63% were university hospitals. Most commonly, TOE would be performed in cases of inadequate or unclear pre-procedural anticoagulation, even in AF lasting <48 h (52% and 50%, respectively), and 15% of centres would perform TOE before AF ablation in all patients. If thrombus was diagnosed despite chronic OAC, the prevalent strategy was to change current OAC to another with different mechanism of action; 51% of centres would wait 3-4 weeks after changing the OAC before using another imaging test, and 60% of centres reported two attempts to dissolve the thrombus. Our survey showed a significant utilization of TOE before CV or AF ablation in European centres, extending beyond AF guidelines-suggested indications. When thrombus was diagnosed despite chronic pre-procedural OAC, most centres would use another anticoagulant drug with different mode of action.
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Affiliation(s)
- Michal M Farkowski
- Heart Arrhythmia Ward, II Department of Coronary Artery Disease, Institute of Cardiology, Alpejska 42, Warsaw, Poland
| | - Kristine Jubele
- P. Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, University of Murcia, Murcia, Spain
| | - Estelle Gandjbakhch
- Sorbonne Universités, APHP, Institute of Cardiology ICAN, Pitié-Salpêtrière University Hospital, Paris, France
| | - Pawel Ptaszynski
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Jose L Merino
- Unidad de Arritmias y Electrofisiología Robotizada, La Paz University Hospital, IDIPAZ, Universidad Autonoma de Madrid, Madrid, Spain
| | - Radoslaw Lenarczyk
- First Department of Cardiology and Angiology, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Tatjana S Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
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Are Three Weeks of Oral Anticoagulation Sufficient for Safe Cardioversion in Atrial Fibrillation? MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57060554. [PMID: 34072778 PMCID: PMC8229733 DOI: 10.3390/medicina57060554] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/18/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022]
Abstract
Background and Objectives: Patients with atrial fibrillation (AF), lasting >48 h, considered for cardioversion, are recommended ≥3 weeks of oral anticoagulation before sinus rhythm restoration because of high risk of development of left atrial thrombosis (LAT) and stroke. However, the optimal duration of anticoagulation in the presence of overt LAT is unknown. Materials and Methods: An open-label study aimed to investigate the prevalence of spontaneous echo contrast (SEC) and LAT before and after 3 weeks of direct oral anticoagulant (DOAC) treatment. We included 51 consecutive patients (50.9% males), mean age 69.3 ± 7.4 years with paroxysmal/unknown duration of AF, considered for cardioversion, who agreed to have transesophageal echocardiography at enrollment and 3 weeks later. Results: At baseline SEC was present in 26 (50.9%) and LAT in 10 (19.6%) of 51 patients. After 3 weeks on DOAC, SEC persisted in 12 (25.0%) and LAT in 7 (14.5%) of 48 patients, p < 0.05 vs. baseline. Factors, associated most strongly with persistence of SEC/LAT, were left atrial appendage (LAA) emptying velocity <20 cm/s (OR = 2.82), LAA lobes >2 (OR = 1.84), and indexed left atrial volume ≥34 mL/m2 (OR = 1.37). Conclusions: In our study the incidence of SEC/LAT, particularly in AF with unknown duration, was not as low as we expected. The prevalence of SEC/LAT seemed to be dependent on factors not routinely evaluated in AF patients planned for cardioversion (indexed LA volume, LAA morphology and number of lobules, LAA emptying velocity, etc.). Our data suggested an individualized approach for DOAC duration in AF patients before an attempt for restoration of sinus rhythm is made, taking into consideration the LAA morphology and function.
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Piotrowski R, Zaborska B, Pilichowska-Paszkiet E, Sikora-Frąc M, Baran J, Kułakowski P. RIVAroxaban TWICE daily for lysis of thrombus in the left atrial appendage in patients with non-valvular atrial fibrillation: the RIVA-TWICE study. Arch Med Sci 2020; 16:289-296. [PMID: 32190138 PMCID: PMC7069443 DOI: 10.5114/aoms.2019.86616] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 02/22/2019] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Rivaroxaban is a direct factor Xa inhibitor used once a day for prevention of thrombotic events in patients with atrial fibrillation (AF). However, in a small proportion of subjects thrombus in the left atrial appendage (LAA) is present despite this treatment. The aim of this study was assess the efficacy of increased dose of rivaroxaban (15 mg twice daily) treatment for lysis of thrombus in the LAA. MATERIAL AND METHODS In the RIVA-TWICE prospective, open label study, with non-blinded patients and blinded outcome assessors, rivaroxaban 15 mg twice daily for 8 weeks was administered in patients with AF who had LAA thrombus despite standard 20 mg once a day therapy. Transesophageal echocardiography was performed at baseline and after 8 weeks. Blood samples were taken to measure the activity of the anti-Xa factor. RESULTS Fifteen patients (9 males, mean age: 63 ±10 years) were enrolled. Following 8 weeks of rivaroxaban 15 mg twice daily, complete resolution of thrombus in the LAA was observed in 7 (46.7%) patients. The mean activity of anti-Xa factor was significantly higher during rivaroxaban twice daily therapy compared with the standard dose. However, there were no significant differences between effectively and non-effectively treated patients. CONCLUSIONS Rivaroxaban 15 mg twice daily seems to be safe and may dissolve LAA thrombus when standard rivaroxaban therapy is ineffective. Lower CHA2DS2-VASc and HAS-BLED as well as preserved LAA emptying function identified responders.
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Affiliation(s)
- Roman Piotrowski
- Postgraduate Medical School, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Beata Zaborska
- Postgraduate Medical School, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | | | - Małgorzata Sikora-Frąc
- Postgraduate Medical School, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Jakub Baran
- Postgraduate Medical School, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Piotr Kułakowski
- Postgraduate Medical School, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
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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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Jariwala P, Kale SS. Resolution of Primary Aortic Thrombosis after Dabigatran therapy-A New Hope for the Rare and Old Disease. Indian Heart J 2019; 71:166-169. [PMID: 31280831 PMCID: PMC6620424 DOI: 10.1016/j.ihj.2019.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/03/2019] [Accepted: 03/26/2019] [Indexed: 11/19/2022] Open
Abstract
The primary aortic thrombosis (PAT) is an uncommon noncardiac cause of distal peripheral embolization to lower extremities. Also, this condition develops in the absence of extensive atherosclerosis of aorta or abnormal dilatation like aneurysm of the aorta. In most of the cases, there was either no or minimal atherosclerosis of the aorta. The disease can involve any part of the aorta, but in most of the cases, the thoracic aorta below the origin of the left subclavian artery followed by the infrarenal portion of the abdominal aorta was the most common site of involvement. In our case, there was extensive thrombosis starting from the lower part of the thoracic aorta extending across both the renal arteries up to the aortic bifurcation without any underlying aortic pathology or hypercoagulable disease. There are no guidelines for the management of the PAT, but our experience is based on few case series, case reports, and meta-analysis where there are variable success rate using conservative medical management, endovascular procedure, or surgical thrombectomy. Vitamin K antagonist was the drug of choice in all the cases as a part of conservative medical management or used to prevent recurrence after the endovascular or surgical procedure. We present a case of PAT where the use of dabigatran leads to complete resolution and prevented the recurrence of the disease during two-year follow-up, which is the first and unique case report of the literature.
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Affiliation(s)
- Pankaj Jariwala
- Department of Cardiology and Cardio-thoracic Surgery, Yashoda Hospitals, Raj Bhavan Road, Somajiguda, Hyderabad, Telangana, 500082, India.
| | - Satya Sridhar Kale
- Department of Cardiology and Cardio-thoracic Surgery, Yashoda Hospitals, Raj Bhavan Road, Somajiguda, Hyderabad, Telangana, 500082, India
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Oyakawa T, Muraoka N, Iida K, Kusuhara M. Effect of Switching from the Initial Direct Oral Anticoagulant to Another One on Exacerbation of Venous Thromboembolism in Patients with Cancer: A Retrospective Study. Ann Vasc Dis 2018; 11:531-534. [PMID: 30637010 PMCID: PMC6326063 DOI: 10.3400/avd.oa.18-00072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: To determine the effect of switching from the initial direct oral anticoagulant (DOAC) to another DOAC on exacerbation of deep vein thrombosis (DVT). Materials and Methods: We retrospectively reviewed the data of patients with advanced cancer who experienced exacerbated DVT during initial treatment with DOAC due to new venous thromboembolism (VTE). After switching to another DOAC for VTE recurrence, changes in the thrombus and bleeding were evaluated for 3 months. Eighteen patients met these criteria. We compared the effect of anticoagulant switching on the switched-drug group in those 18 patients with the effect of no anticoagulant switching on the single-drug group of patients (n=78) with a similar background. Results: The recurrence rate of VTE in the switched-drug group was 6%. Non-major bleeding occurred in 11% of patients. Recurrent VTE occurred in 6% of patients in both the switched-drug and single-drug groups, respectively [risk ratio (RR): 0.9, 95% confidence interval (CI): 0.11–7.6]. Non-major bleeding occurred in 11% and 14% of patients in the switched-drug and single-drug groups, respectively (RR: 0.79, 95%CI: 0.19–3.2). Conclusion: Switching DOAC may be a treatment option for exacerbation of DVT in patients with advanced cancer.
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Affiliation(s)
- Takuya Oyakawa
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kei Iida
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan
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Sun H, Zhao Q, Wang Y, Lakin R, Liu X, Yu M, Yang H, Gao D, Chen W, Gao G, Yan M, He Y, Yang P. Dabigatran as an alternative for atrial thrombosis resistant to rivaroxaban: A case report. Medicine (Baltimore) 2018; 97:e13623. [PMID: 30572474 PMCID: PMC6319865 DOI: 10.1097/md.0000000000013623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Anti-thrombosis therapy for atrial fibrillation (AF) management and stroke prevention is an important aspect of disease management. Novel oral anticoagulants (NOACs) are recommended by guidelines for AF management. However, if one can switch one NOAC to another when the former showed a poor effect has not been fully determined. PATIENT CONCERNS A 52-year-old man was admitted to our center for heart failure and AF with a thrombus in the left atrium. DIAGNOSES Cardiomyopathy was diagnosed by cardiac magnetic resonance (CMR) and echocardiography. INTERVENTIONS He was prescribed rivaroxaban (20 mg daily) as treatment, and dabigatran (150 mg twice daily) was used when the thrombus was found to be non-response to rivaroxaban. OUTCOMES The rivaroxaban did not diminish the atrial thrombus, and dabigatran was given instead which finally eliminated the thrombus. LESSONS Individualized responsiveness to NOACs should be considered and paid more attention to during clinical practice.
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Affiliation(s)
- Huan Sun
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | - Qini Zhao
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | | | - Robert Lakin
- Department of Exercise Sciences, University of Toronto, Toronto, Canada
| | - Xueyan Liu
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | - Ming Yu
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | - Hongliang Yang
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | - Dongmei Gao
- Ultrasound Department, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Weiwei Chen
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | - Guangyuan Gao
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | - Mengjie Yan
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | - Yuquan He
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
| | - Ping Yang
- Cardiology Department, China-Japan Union Hospital of Jilin University
- Jilin Provincial Cardiovascular Research Institute
- Jilin Provincial Key Laboratory for Genetic Diagnosis of Cardiovascular Disease
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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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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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