Resolution of left atrial appendage thrombus with apixaban
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CASE REPORT
Open Access
Resolution of left atrial appendage thrombus with apixaban Tohru Kawakami*, Hiroko Kobayakawa, Hiroyoshi Ohno, Nobukiyo Tanaka and Hiroki Ishihara
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). Keywords: Atrial fibrillation, Left atrial appendage thrombus, Apixaban
Background Left atrial appendage (LAA) thrombus is commonly associated with atrial fibrillation (AF) and causes thromboembolic complications. Warfarin is used for prevention of thromboembolic complications with AF patients and resolution of LAA thrombus [1]. Apixaban is a member of the class of novel oral anticoagulants (NOAC). It is superior to warfarin in preventing stroke or systemic embolism, and causes less bleeding [2]. Few reports exist detailing resolution of LAA thrombus with other novel oral anticoagulants (NOAC) [3,4]. Case presentation A 72-year-old male consulted our hospital due to dyspnea and palpitation, maintained for one week or more. On hospital admission the patient presented with functional NYHA class III; he had a clinical history of non-ischemic cardiomyopathy with severely impaired left ventricular function and a moderate AF-related thromboembolic risk with an actual CHA2DS2VASc score of 3, and had not been pretreated with anticoagulant. We determined that he required rapid anticoagulation to be delivered orally. We started oral anticoagulation (OAC) therapy with the direct factor Xa (FXa) inhibitor apixaban (5 mg twice daily). The patient had high levels of soluble fibrin (SF) * Correspondence: [email protected] From the Division of Cardiology, Ichinomiyanishi Hospital, 1 Kaimei-hira, Ichinomiya, Aichi, Japan
and D-dimer, normal levels of international normalized ratio (INR) and activated partial thromboplastin time (APTT) on hospitalization. We performed transesophageal echocardiography (TEE), which revealed formation of a small thrombus (11 × 10 mm) in the left atrial appendage (LAA) (Figure 1A). After 16 days of apixaban treatment TEE showed complete thrombus resolution (Figure 1B). During apixaban treatment SF and D-dimer changed as the day passed; SF fell, while there was a rise and subsequent fall in D-dimer, without prolongation of INR or APTT (Figure 1C). Finally, catheter ablation of persistent AF was performed successfully without clinical signs of cardiac embolism after 22 days
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