Resolution of massive left atrial appendage thrombi with rivaroxaban before balloon mitral commissurotomy in severe mitral stenosis

Abstract

Rationale:Data on nonvitamin K antagonist oral anticoagulant being used for the treatment of LAA thrombi are limited only in nonvalvular atrial fibrillation. There are no data on the antithrombotic efficacy and safety of nonvitamin K antagonist oral anticoagulant in the resolution of left atrial appendage (LAA) thrombi in patients with rheumatic mitral stenosis.Patient concerns:A 49-year-old woman with known rheumatic mitral stenosis and atrial fibrillation was referred for percutaneous transvenous mitral commissurotomy because of progressive dyspnea on exertion over a period of 3 months.Diagnoses:Transesophageal echocardiography (TEE) demonstrated a large LAA thrombus protruding into left atria cavity before the procedure.Interventions:Direct factor Xa (FXa) inhibitor rivaroxaban (20 mg/d) was started for the patient. After 3 weeks of rivaroxaban treatment TEE showed a relevantly decreased thrombus size, and a complete thrombus resolution was achieved after 5 weeks of anticoagulant therapy with the FXa inhibitor.Outcomes:To the best of our knowledge, this is the first documented case of large LAA thrombus resolution with nonvitamin K antagonist oral anticoagulant in severe mitral stenosis, and in which percutaneous transvenous mitral commissurotomy was performed subsequently.Lessons:The report indicated that rivaroxaban could be a therapeutic option for mitral stenosis patients with LAA thrombus. Further study is required before the routine use of rivaroxaban in patients with rheumatic mitral stenosis and atrial fibrillation.

Warfarin vs non‐vitamin K oral anticoagulants for left atrial appendage thrombus: A meta‐analysis

“…Current guidelines recommend VKA therapy for LAA thrombus in patients with AF and the data regarding NOAC use for LAA thrombus in non‐valvular AF are limited to mainly case reports or case series. Use of VKA is limited by frequent INR checks prompting dose adjustment, compliance with certain diets, and hence NOACs provide some benefit with regard to reduced drug interactions and lack of need for coagulation monitoring 8 …”

“…Use of VKA is limited by frequent INR checks prompting dose adjustment, compliance with certain diets, and hence NOACs provide some benefit with regard to reduced drug interactions and lack of need for coagulation monitoring. 8 In a retrospective study by Graham et al 9 Note: A study can be awarded a maximum of four stars for selection, two stars for comparability, and three stars for outcome.…”

RIVAroxaban TWICE daily for lysis of thrombus in the left atrial appendage in patients with non-valvular atrial fibrillation: the RIVA-TWICE study

“…To date, a total of 14 studies [14][15][16] have reported the use of all types of NOAC, including rivaroxaban, for the resolution of LAA thrombus in patients with non-valvular AF in whom previous anticoagulation was ineffective. These studies generally indicated beneficial results -the change of anticoagulant agent resulted in resolution of thrombus.…”

“…These studies generally indicated beneficial results -the change of anticoagulant agent resulted in resolution of thrombus. However, most of these studied are case reports and only standard doses of anticoagulants were used [15,16]. Three case reports demonstrated resolution of thrombus in the LAA during rivaroxaban once a day therapy.…”

Thrombosis of Left Atrial Appendage During Therapy With Direct Oral Anticoagulant. Clinical Case

“…Обращает на себя внимание даже сообщение Li Y. и соавт. об успешном использовании ППОАК ривароксабана при тромбозе ушка ЛП у пациентки с митральным стенозом ревматической этиологии [39].…”