Oral factor Xa inhibitors for the treatment of left ventricular thrombus: a case series

Abstract

Left ventricular thrombus (LVT) formation usually necessitates short term anticoagulation for thrombus resolution and to prevent embolic events. Historically, vitamin K antagonist therapy has been the treatment of choice. However, with the advent of direct acting anticoagulants, their role in the management of LVT is not clear. Patients were included if they had received rivaroxaban or apixaban for more than 1 day for LVT documented on imaging. The primary objective was resolution of LVT at 3 months based on assessment by an independent cardiologist review of initial and subsequent imaging results. The principle safety objective was to assess major or clinically relevant non-major bleeding using GUSTO, TIMI, and BARC bleeding criteria. During the 2-year study period seven patients were treated with rivaroxaban and three with apixaban. Two patients who had received apixaban and one on rivaroxaban were lost to follow up. In those with an initial and follow-up ECHO (n = 6) the median time to follow up imaging was 214 (IQR 33-414) days and complete LVT resolution was observed in 83% of patients. One patient on rivaroxaban had a bleeding events that was minimal (TIMI), Type 2 (BARC), or classified as mild (GUSTO) due to pulmonary hemorrhage. In those deemed not to be a candidate for vitamin K antagonist the use of rivaroxaban or apixaban may be a considered in the treatment of LVT. Further research in this area is needed to assess the efficacy and safety of using FXAI for treatment of LVT.

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

“…Previously, evidence for the use of DOACs in the setting of LVT have been confined to case reports and case series, and there remain limited comparative studies of DOACs versus VKA. 16 -29…”

“…Previously, evidence for the use of DOACs in the setting of LVT have been confined to case reports and case series, and there remain limited comparative studies of DOACs versus VKA. [16][17][18][19][20][21][22][23][24][25][26][27][28][29] The aim of our study is to add to the current body of literature to assess the safety and efficacy of DOACs compared to VKA for the treatment of LVT in 2 large academic hospitals. We further pooled data of our study with existing studies and performed a meta-analysis to examine the effect of DOAC versus VKA in the treatment of LVT.…”

Dabigatran Added to Dual Antiplatelet Therapy to Treat a Left Ventricular Thrombus in an 87 Year Old Patient With Myocardial Infarction and Very High Bleeding Risk

“…Nieman et al reported that anticoagulation with warfarin therapy can resolve fresh thrombi, but not chronic ventricular thrombi after MI (Niemann et al, 2012 ). However, several case reports have shown the feasibility of NOAC treatment of LV thrombi with dabigatran (Kaku, 2013 ; Nagamoto et al, 2014 ; Chung et al, 2015 ; Kolekar et al, 2015 ; Ohashi et al, 2015 ) or factor Xa inhibitors (Nakasuka et al, 2014 ; Padilla Pérez et al, 2014 ; Kaya et al, 2016 ; Makrides, 2016 ; Mano et al, 2016 ; Berry et al, 2017 ; Seecheran et al, 2017 ; Smetana et al, 2017 ). In the cases describing dabigatran to resolve LV thrombi, the doses varied between 110 and 150 mg bid and the resolution of the thrombi was confirmed after 3 weeks to 4 months (Hori et al, 2013 ).…”

“…We chose dabigatran due to the high bleeding risk of our patient and the availability of an efficient antidote (idarucizumab), which had shown rapid and complete reversion of the anticoagulant activity of dabigatran in the RE-VERSE AD study (Pollack et al, 2015 ). Only few cases have been reported in the literature where triple therapy was used to resolve a LV thrombus with Factor Xa inhibitors (Makrides, 2016 ; Mano et al, 2016 ; Berry et al, 2017 ; Seecheran et al, 2017 ; Smetana et al, 2017 ) or dabigatran (Chung et al, 2015 ; Ohashi et al, 2015 ). In contrast to these described cases, apparent development of a LV thrombus under dabigatran treatment has been published recently (Adar et al, 2018 ).…”

Biventricular Thrombi in Substance-Induced Dilated Cardiomyopathy

“…There have been several publications describing the use of rivaroxaban or apixaban in the successful treatment of left ventricular thrombi. 1,[12][13][14][15] Patients falling into this category include those with abnormal liver function, concurrent use of cytochrome P450 inhibitors, histories of liable INRs, and poor follow-up for INR. 12,13 Although these medications are not recommended as first-line therapy for biventricular thrombi, they do offer an intriguing alternative treatment approach.…”