Efficacy of Direct Acting Oral Anticoagulant Drugs in Treatment of Left Atrial Appendage Thrombus in Patients With Atrial Fibrillation

Fleddermann, Adam; Eckert, Ryan; Muskala, Preetham; Hayes, Charles H.; Magalski, Anthony; Main, Michael L.

doi:10.1016/j.amjcard.2018.09.026

Cited by 24 publications

(26 citation statements)

References 9 publications

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“…Repeat TEE was performed at 12 weeks, with complete resolution observed in 32 (80%) subjects in the rivaroxaban group 13 . Fleddermann et al 14 reported a retrospective cohort study in 16 patients with AF who were treated with NOACs for LAA thrombus. None of the patients had taken an oral anticoagulant before the index medical encounter.…”

Section: Discussionmentioning

confidence: 99%

Outcome of non‐vitamin K oral anticoagulants in the treatment of left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation

Lin

Quan

Bao

et al. 2020

Cardiovasc electrophysiol

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Background Data comparing dabigatran with rivaroxaban regarding the resolution of left atrial/left atrial appendage (LA/LAA) thrombus in patients with nonvalvular atrial fibrillation (AF) are scarce. This study aimed to compare the efficacy and safety of dabigatran vs rivaroxaban regarding the resolution of LA/LAA thrombus in patients with nonvalvular AF. Methods This retrospective study enrolled nonvalvular AF patients scheduled to undergo catheter ablation or cardioversion in Shanghai Ruijin Hospital between January 2014 and January 2019. Altogether, 34 patients with LA/LAA thrombus detected by transesophageal echocardiography (TEE) were enrolled. Among them, 12 patients were treated with dabigatran 150 mg bid and the other 22 with rivaroxaban 20 mg qd. Follow‐up TEE was performed within greater than or equal to 3 weeks to less than 6 months of the initial TEE to evaluate the resolution of the LA/LAA thrombus. Results Baseline patient characteristics were similar in the two groups. Overall, 18 patients (81.8%) in the rivaroxaban group had complete thrombus resolution after 70.3 ± 22.1 treatment days, and 10 patients (83.3%) in the dabigatran group had complete thrombus resolution after 69.3 ± 47.9 treatment days. There was no significant difference between the groups (P = .6). TEE showed that the average length, width, and area of thrombus significantly decreased in both groups after treatment, although there was no significant difference in the amount of change in these parameters between the two groups after treatment (P = .6). Undissolved thrombus in two patients in the rivaroxaban group did dissolve after switching to dabigatran. Conclusions The results suggest that both dabigatran and rivaroxaban are potential options for treating LA/LAA thrombus in patients with nonvalvular AF. Dabigatran could be an alternative option for the resolution of LA/LAA thrombus resistant to rivaroxaban.

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Section: Discussionmentioning

confidence: 99%

Outcome of non‐vitamin K oral anticoagulants in the treatment of left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation

Lin

Quan

Bao

et al. 2020

Cardiovasc electrophysiol

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“…Nevertheless, there is uncertainty regarding the application of these results for the management of LA thrombus. To the best of our knowledge, there have been only five publications on NOACs to date where all or the majority of subjects with AF or flutter were OAC naïve at the time of initial diagnosis of LA thrombus . Only three had warfarin comparison groups …”

Section: Discussionmentioning

confidence: 99%

“…To the best of our knowledge, there have been only five publications on NOACs to date where all or the majority of subjects with AF or flutter were OAC naïve at the time of initial diagnosis of LA thrombus. [19][20][21][22][23] Only three had warfarin comparison groups. 19,20,23 Hao Ultimately, multicenter randomized controlled trials to compare individual NOACs to warfarin or other NOACs should be performed.…”

Section: Discussionmentioning

confidence: 99%

“…Lack of prior long-term OAC use at the time of initial LA thrombus diagnosis was not explicitly reported. Fleddermann et al reported a retrospective cohort study from St. Luke's Mid America Heart Institute in 16 patients with AF whowere treated with NOACs for LA appendage thrombus 22. None of the patients received OAC agents prior to the index medical encounter.…”

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confidence: 99%

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Non‐vitamin K oral anticoagulants versus warfarin for left atrial appendage thrombus resolution in nonvalvular atrial fibrillation or flutter

Hussain

Katz

Genuardi

et al. 2019

Pacing Clinical Electrophis

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Background Non‐vitamin K oral anticoagulants (NOACs) have emerged as alternatives to vitamin K antagonists in select situations. For left atrial (LA) appendage thrombus in nonvalvular atrial fibrillation (AF) or flutter, guidelines recommend oral anticoagulation (OAC) for at least 3 weeks prior to reassessment. Data comparing NOACs to warfarin in this scenario are scarce. Methods A retrospective study identified subjects with nonvalvular AF or flutter who were: a) noted to have LA thrombus detected on transesophageal echocardiography (TEE), b) previously not receiving long‐term OAC; and c) evaluated for resolution of LA thrombus by follow‐up TEE between 3 weeks to less than 1 year of the initial TEE. Results The study included 45 subjects with mean age 63.2 years, 69% male, 78% white race/ethnicity, 42% paroxysmal, and mean CHA2DS2‐VASc score 3.4 ± 1.7. All LA thrombi were confined to the appendage. OAC received included apixaban (3), dabigatran (13), rivaroxaban (6), and warfarin (23), The median follow‐up time to repeat TEE was 67 (interquartile range, 49‐96) days. LA appendage thrombus resolution rates were 76% for the entire cohort, 77% for NOACs, and 74% for warfarin. In univariable logistic regression analysis, LA appendage thrombus resolution was similar for NOACs when compared to warfarin (odds ratio, 1.20; 95% confidence interval, 0.31‐4.69; P = .79). Conclusions In patients nonvalvular AF or flutter who were OAC naïve at the time of diagnosis with LA appendage thrombus, complete resolution was similar between NOACs and warfarin.

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“…19 There are also data to support the use of DOAC to prevent thromboembolism in those with left atrial thrombus. 20,21 Anticoagulation for the prevention of vascular events in heart failure…”

Section: Direct Oral Anticoagulant For the Prevention Of Stroke In Nomentioning

confidence: 99%

Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus

et al. 2020

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Aims Left ventricular (LV) thrombus is increasingly detected in patients with and without ischaemic heart disease due to the increased availability of cardiac magnetic resonance imaging. Risk factors include anterior ST elevation myocardial infarction, delayed reperfusion therapy, and non-ischaemic cardiomyopathy with severe LV systolic dysfunction. We aimed to report the characteristics and outcomes of patients with LV thrombus treated with either vitamin K antagonist (VKA) or direct oral anticoagulants (DOAC) with a view to describing differences in efficacy, specifically, subsequent thromboembolic events, thrombus resolution, and also side effects of therapy including clinically significant bleeding. Methods and results We conducted a retrospective, observational cohort study of patients diagnosed with LV thrombus between 1 December 2012 and 30 June 2018 and treated with either DOAC or VKA. We recorded patient demographics, past medical history, prescribed medications, and baseline investigations. The primary outcomes were rates of thromboembolism and clinically significant bleeding, with secondary outcomes of thrombus resolution on repeat cardiac imaging, repeat hospitalization, and all-cause mortality. During the study period, 84 patients were diagnosed with and managed for LV thrombus. Of these, 62 received VKA and 22 DOAC including 13 prescribed rivaroxaban, eight apixaban, and one dabigatran. Most patients 75 (89%) were male with an average age of 62 ± 14 years. Ischaemic heart disease was the cause of LV impairment in 73 (87%) patients. Baseline characteristics were similar between groups at baseline. Most n = 55 (65%) were co-prescribed a single antiplatelet agent and 32 (38%) received dual-antiplatelet therapy. During an average follow-up of 3.0 ± 1.4 years, there were no statistically significant differences between VKA and DOAC in rates of stroke (2% vs. 0%, P = 0.55), other thromboemboli (2% vs. 0%, P = 0.55), or clinically significant bleeding (10% vs. 0%, P = 0.13). The average interval to cardiac imaging follow-up was 233 ± 251 days and was not different between groups (P = 0.83), and there was no difference in the rate of resolution of thrombus (76% vs. 65% P = 0.33). Rehospitalization (50% vs. 45%: P = 0.53) and all-cause mortality (10% vs. 14%; P = 0.61) were also similar. Conclusions Our data suggest that DOACs are likely to be at least as effective and safe as VKA for stroke prevention in patients with LV thrombus and, despite their lack of a licence for this indication, are therefore likely to represent a reasonable and more convenient option for this setting. The optimal timing and type of anticoagulation for LV thrombus, as well as the role of screening for high-risk patients, should be tested in prospective, randomized trials.

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Efficacy of Direct Acting Oral Anticoagulant Drugs in Treatment of Left Atrial Appendage Thrombus in Patients With Atrial Fibrillation

Cited by 24 publications

References 9 publications

Outcome of non‐vitamin K oral anticoagulants in the treatment of left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation

Outcome of non‐vitamin K oral anticoagulants in the treatment of left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation

Non‐vitamin K oral anticoagulants versus warfarin for left atrial appendage thrombus resolution in nonvalvular atrial fibrillation or flutter

Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus

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