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Table of Contents
CASE REPORT  
Year : 2018  |  Volume : 21  |  Issue : 1  |  Page : 76-77
Successful resolution with apixaban of a massive left atrial appendage thrombus due to nonrheumatic atrial fibrillation: A case report and review


1 Department of Cardiology, St. Joseph's Regional Medical Center, Paterson, NJ, USA
2 Department of Hematology and Oncology, St. Michael's Medical Center, Newark, NJ, USA

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Date of Web Publication11-Jan-2018
 

   Abstract 


A 32-year-old woman with a past medical history of paroxysmal atrial fibrillation, long QT syndrome, and implantation of an automatic iimplantable cardioverter-defibrillator (AICD) following cardiac arrest presented with disabling symptoms of paroxysmal atrial fibrillation due to recurrent AICD shocks. Before curative ablation, transesophageal echocardiography was performed to assess for existing thrombi. This is a rare case of successful resolution with apixaban of a massive left atrial appendage thrombus due to non-rheumatic atrial fibrillation that was successfully treated with apixaban.

Keywords: Apixaban, atrial fibrillation, atrial thrombus

How to cite this article:
Ghalyoun BA, Lempel M, Shaaban H, Shamoon F. Successful resolution with apixaban of a massive left atrial appendage thrombus due to nonrheumatic atrial fibrillation: A case report and review. Ann Card Anaesth 2018;21:76-7

How to cite this URL:
Ghalyoun BA, Lempel M, Shaaban H, Shamoon F. Successful resolution with apixaban of a massive left atrial appendage thrombus due to nonrheumatic atrial fibrillation: A case report and review. Ann Card Anaesth [serial online] 2018 [cited 2019 Nov 17];21:76-7. Available from: http://www.annals.in/text.asp?2018/21/1/76/223026





   Introduction Top


Thrombus has a predilection to develop in the left atrial appendage due to its shape and composite trabeculations.[1] This is particularly true in any cardiac pathology with resultant stasis, such as atrial fibrillation. Moreover, since the Framingham study showed that atrial fibrillation increases the risk for stroke 5-fold,[2] monitoring and treatment of thrombi is necessary. Transesophageal echocardiography has made clear imaging of the left atrial appendage possible, allowing its size, shape, flow patterns, and content to be assessed. This has allowed a more accurate assessment of the left atrial appendage for thrombus before cardioversion in patients with atrial fibrillation. While warfarin has preferably been the standard medication to decrease thromboembolic events in atrial fibrillation patients, factors such as regular international normalized ratio monitoring, variable dosing, food-drug interactions, and drug–drug interactions limit warfarin's practicality. Direct oral anticoagulants (DOACs) have been shown to be effective in decreasing stroke risk with fewer drug interactions, easier dosages, and no need for monitoring, thus providing a sound alternative to warfarin.[3] Nevertheless, limited data involving the use of direct oral anticoagulants as thrombolytics exists.[4] Herein, we report an interesting case of a patient who presented with a massive left atrial appendage thrombus secondary to nonvalvular atrial fibrillation which was successfully treated with apixaban anticoagulation.


   Case Report Top


A 32-year-old woman with a past medical history of paroxysmal atrial fibrillation, long QT syndrome, and implantation of an automatic implantable cardioverter- defibrillator (AICD) following cardiac arrest presented with disabling symptoms of paroxysmal atrial fibrillation due to recurrent AICD shocks. Upon presentation, the patient had a CHA2DS2-VASc score of 1 and was not receiving any anticoagulant therapy. Before curative ablation, transesophageal echocardiography [Figure 1]a and [Figure 1]b was performed to assess for existing thrombi. On examination, a large thrombus was noted on the left atrial appendage measuring (3.9 cm × 2.86 cm). This finding contraindicated curative ablation due to the risk of embolization. Following this discovery, the patient was started on apixaban 5 mg twice daily and scheduled for reevaluation with an additional transesophageal echocardiography 5 weeks later. As shown in [Figure 2]a and [Figure 2]b, on reevaluation the massive left atrial appendage had completely resolved. One week following the second tranesophageal echocardiography, the patient was able to undergo curative ablation with resultant atrial paced sinus rhythm as per her postprocedure electrocardiogram. Despite the development of a massive left atrial appendage thrombus, the patient was able to undergo curative ablation only 7 weeks following its discovery and was sent home on apixaban 5 mg twice daily and metoprolol tartate 100 mg twice daily.
Figure 1: (a and b) Tee done Revealed A 3.9 cm × 2.86 cm LAA thrombus

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Figure 2: (a and b) Tee done revealed resolution of atrial thrombus after apixaban therapy

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   Discussion Top


Nonrheumatic atrial fibrillation is the most common cause of cerebral embolism overall. The presumed stroke mechanism is thrombus formation in the fibrillating atrium or atrial appendage, with subsequent embolization.[5] As shown in our case, apixaban can successfully resolve large left atrial appendage thrombi in a relatively short period, thus providing a sound alternative to warfarin treatment. DOACs directly inhibit thrombin or factor Xa in the clotting cascade and hence potentiate thrombolytic properties. Inhibition of factor Xa blocks the production of thrombin. Thus, DOACs have the potential not only contribute to the prevention of de novo thrombi but also enable the resolution of established thrombi. Recent reports have demonstrated that direct factor Xa inhibitors such as apixaban possess the ability to inhibit thrombin generation and platelet aggregation derived through the tissue factor pathway to a more effectively greater extent than direct thrombin inhibitors do.[6] Furthermore, there are other published case reports where apixaban dissolved existing left atrial thrombi. For example, 2.5 mg twice daily of apixaban partially dissolved a large thrombus in the left atrium from (4.8 cm × 2.2 cm) to (1.5 cm × 0.6 cm) in 11 weeks.[7] In another case study, 5 mg twice daily apixaban was used to resolve a small left atrial appendage thrombus measuring (1.1 cm × 1 cm) in 16 days.[8] The results of these cases suggest that apixaban is a potential alternative to warfarin to resolve existing left atrial thrombi. However, Ohyagi et al. reported a case where a patient had an embolic stroke during apixaban therapy for an existing left atrial appendage thrombus.[9] Therefore, more research is needed. The Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study demonstrated that the use of 5 mg twice daily apixaban as equated to warfarin significantly reduced the risk of stroke or systemic embolism by 21%, major bleeding by 31% and death by 11% as compared to warfarin.[10] Perhaps the next step requires performing a similar trial to analyze resolution of existing left atrial thrombi by apixaban as compared to warfarin.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Al-Saady NM, Obel OA, Camm AJ. Left atrial appendage: Structure, function, and role in thromboembolism. Heart 1999;82:547-54.  Back to cited text no. 1
    
2.
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: The Framingham study. Stroke 1991;22:983-8.  Back to cited text no. 2
    
3.
Kailas SD, Thambuluru SR. Efficacy and safety of direct oral anticoagulants compared to warfarin in prevention of thromboembolic events among elderly patients with atrial fibrillation. Cureus 2016;8:e836.  Back to cited text no. 3
    
4.
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr., et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;64:e1-76.  Back to cited text no. 4
    
5.
Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. 19th ed. New York: McGraw-Hill Education; 2015.  Back to cited text no. 5
    
6.
Wan H, Yang Y, Zhu J, Wu S, Zhou Z, Huang B, et al. An in-vitro evaluation of direct thrombin inhibitor and factor Xa inhibitor on tissue factor-induced thrombin generation and platelet aggregation: A comparison of dabigatran and rivaroxaban. Blood Coagul Fibrinolysis 2016;27:882-5.  Back to cited text no. 6
    
7.
Dobashi S, Fujino T, Ikeda T. Use of apixaban for an elderly patient with left atrial thrombus. BMJ case reports. 2014 Jun 24;2014:bcr2014203870.  Back to cited text no. 7
    
8.
Kawakami T, Kobayakawa H, Ohno H, Tanaka N, Ishihara H. Resolution of left atrial appendage thrombus with apixaban. Thromb J 2013;11:26-8.  Back to cited text no. 8
    
9.
Ohyagi M, Nakamura K, Watanabe M, Fujigasaki H. Embolic stroke during apixaban therapy for left atrial appendage thrombus. J Stroke Cerebrovasc Dis 2015;24:e101-2.  Back to cited text no. 9
    
10.
Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981-92.  Back to cited text no. 10
    

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Correspondence Address:
Hamid Shaaban
111 Central Avenue, Newark, NJ
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_146_17

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