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Anaemia, epistaxis and left atrial appendage thrombus: case report A 74-year-old woman developed left atrial appendage thrombus on pro-coagulant tranexamic acid and epistaxis with anaemia during treatment with apixaban for postoperative anticoagulant therapy [not all routes, dosages, time to reactions onset and outcomes stated]. The woman, who had a history of hereditary hemorrhagic telangiectasia complicated by severe bi-atrial enlargement with chronic atrial fibrillation, mild aortic stenosis, recurrent epistaxis, liver arteriovenous malformations, and right iliac artery arteriovenous malformation status post embolisation, presented to the cardiology department of the hospital. She also had a history of severe nosebleeds and had not been anticoagulated. She had been receiving treatment with oral tranexamic acid continuously since 2014 to manage her epistaxis. During current presentation, an echocardiogram revealed a 3.1 ×3.2 cm echodense mobile mass in the left atrium attached to the intra-atrial septum on a stalk to reassess her cardiac function. A cardiac magnetic resonance study showed the following: an enlarged left atrium with a 2.7 ×2.8 cm mobile, nonenhancing mass with T1 hyperintensity attached to the anterosuperior intra-atrial septum by a thin stalk and a second mass measuring 8 ×5 mm in the left atrial appendage. Due to the concern for left atrial thrombus with high risk of embolisation, she underwent surgical resection of the thrombus of the atrial mass, left atrial appendage closure, and Cox-Maze IV procedure. Intraoperative findings showed the following: a 3.5 ×3.0 ×1.3 cm mass attached to the intra-atrial septum and a smaller mass in the left atrial appendage. Both masses was consistent with organizing mural thrombus. The woman’s treatment with tranexamic acid was discontinued. Postoperatively, she was started on low-dose apixaban 2.5mg twice daily. She subsequently developed severe epistaxis with anaemia (haemoglobin: 7 g/dL) during apixaban treatment. Her treatment with apixaban was discontinued and she was treated with an infusion course of bevacizumab. Shahandeh N, et al. Left atrial thrombus mimicking myxoma in a patient with hereditary hemorrhagic telangiectasia: Diagnostic and therapeutic dilemmas. Radiology Case 803501927 Reports 15: 1909-1914, No. 10, Oct 2020. Available from: URL: http://doi.org/10.1016/j.radcr.2020.07.050

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