Rapid resolution of left ventricular thrombus with apixaban therapy

Abstract

It is a common medical practice to anticoagulate an asymptomatic left ventricular mural thrombus following an ST-elevation myocardial infarction using a vitamin K antagonist. Novel oral anticoagulants have not been studied extensively in this context, and therefore, no recommendations have been made for their use. A 67-year-old male physician with no significant medical history presented to the cardiology clinic complaining of shortness of breath that had been gradually worsening over a 2-week period and was found to have an anterior wall myocardial infarction with apical left ventricular thrombus that was treated with apixaban. We present a case of rapid resolution of left ventricular thrombus with the use of apixaban for anticoagulation. Although there are no guideline recommendations for this use, there have been case series and case reports that have shown safety and efficacy. Apixaban can be used for rapid resolution of left ventricular thrombus treatment.

The concoction of cancer, catheter, and intracardiac clot: a case report describing a potential treatment strategy

“…There have also been several case reports describing the effectiveness of DOACs in the treatment of left ventricular (LV) thrombus. 9 , 10 However, the literature describing the use of DOACs to treat right-sided thrombus is sparse and large-scale randomized control trials (RCT) are lacking in this area. Even the current recommendations to use oral vitamin K antagonists for left-sided intracardiac clots are largely based on observational studies and not RCTs, as RCTs would be rather difficult to conduct in this cohort.…”

“…There were no clear guidelines on how to manage this unique situation and the patient preferred an oral anticoagulant that did not require frequent monitoring. Due to the efficacy and safety profile of apixaban, 17 and its success in treating intracardiac thrombus, 9 , 10 we decided to treat our patient with apixaban. After discussing the potential risks and benefits, the patient was started on apixaban 10 mg twice daily initially for 7 days and then 5 mg a day thereafter.…”

The role of rivaroxaban in left ventricular thrombi

“…Rivaroxaban was also used for treating a case of intraventricular thrombus in Chagas disease (13) and dilated cardiomyopathy (14). Several reported cases have shown the efficacy of apixaban in cases of intraventricular thrombi without increased risk of thromboembolic or bleeding issues even when used with DAPT in patients with post-MI (15, 16).…”

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 ).…”