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Table 1. (continued) Variables NASH* with Thromboembolism** N56,820(1.6%) NASH without Thromboembolism** N5429,025(98.4%) P-Value Peripheral vascular disease 5.6% 4.6% , 0.001 COPD*

Introduction: Aberrant cardiac structures reported on echocardiography include aberrant papillary muscles, accessory chordae tendineae, ventricular bands, and accessory mitral valve tissue. These usually present with conduction abnormality, obstruction, and heart failure. We report a diagnostic dilemma with a structurally anomalous chord noted on the echocardiogram presenting as recurrent stroke. Case: A 70 year old man presented with complaints of left facial droop, confusion and slurred speech, currently on aspirin and clopidogrel. CT head and MRI brain revealed right middle cerebral artery occlusion and acute on chronic infarcts in multiple vascular territories. Past medical history of recurrent strokes involving the right frontal, occipital lobes, and thalamus suggested embolic aetiology. Transthoracic and Transesophageal Echocardiographic (TEE) examination revealed an anomalous redundant chordal tissue attached to the papillary muscle with no distal attachment, normal mitral valve function without left ventricular outflow tract obstruction. This anomalous chord was present on TEE done 1 year prior but not well visualised at that time. Differentials included ruptured aberrant ventricular band, ruptured chordae tendineae, ruptured papillary muscle with a thrombus or vegetation formation. Due to the chronicity of the condition and negative blood cultures, vegetation was less likely. Recurrent mural thrombus associated with the aberrant chord was identified as the culprit and patient was started on anticoagulation to prevent stroke. Results: All of the aberrant structures reported in current literature have been characterized based on their distal attachment. We excluded accessory papillary muscle and chordae tendineae from the list of differentials as its rupture presents as mitral regurgitation and acute heart failure. The most plausible explanation includes a ruptured false tendon serving as a nidus for thrombus formation with no prior echocardiographic evidence of distal attachment of the fibrous chord. Conclusions: Our case illustrates a very rare entity of an idiopathic primary rupture of a left ventricle false tendon serving as a nidus for clot formation leading to recurrent stroke warranting anticoagulation.

A major advancement in the field of medicine has been the introduction and usage of direct oral anticoagulants (DOACs) such as dabigatran (Pradaxa), apixaban (Eliquis), and rivaroxaban (Xarelto). DOACs have been increasing in popularity for mainstay anticoagulation pharmacotherapy and are being preferred by physicians over warfarin due to their rapid onset, fewer drug and food interactions, and lack of frequent blood monitoring. DOACs have been indicated in the management of thromboembolic conditions and have been extensively researched in various medical trials and studies before the approval of dabigatran (Pradaxa) in 2010 by the FDA. DOACs, like warfarin, are associated with a risk of bleeding, requiring clearance of the drug from the bloodstream or administration of reversal agents. It is important for physicians to familiarize themselves with the various types of DOACs and their dosages, along with their advantages and disadvantages in comparison to other non-DAOC classes of medications before incorporating them into their patient management plans.

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