Two-week administration of rivaroxaban resolved left atrial thrombus

Abstract

The incidence of nonvalvular atrial fibrillation increases with age, and left atrial thrombus complicated with nonvalvular atrial fibrillation is the major direct cause of cardiogenic thromboembolism that we need to prevent. Intravenous heparin and oral vitamin-K antagonist warfarin have been the most popular and the most frequently used agents for the treatment of left atrial thrombus in patients with atrial fibrillation [1]. Recently, novel oral anticoagulants such as a direct thrombin inhibitor dabigatran or a direct factor Xa inhibitor rivaroxaban have been developed, and we can use these agents in the clinical settings to prevent cardiogenic thrombo-embolism in patients with nonvalvular atrial fibrillation [2]. We experienced an atrial fibrillation patient with intracardiac large thrombus, which shrunk and then disappeared during a short period after starting treatment with rivaroxaban. Case reportAn 89-year-old man visited our hospital complaining of palpitation. Blood pressure was 156/88 mmHg and electrocardiography showed atrial fibrillation with a ventricular rate of 88. Blood tests revealed hemoglobin A1c 7.9%, brain natriuretic peptide 175.6 pg/ml, D-dimer 1.7 mg/ml, prothrombin timeinternational normalized ratio 1.08, activated partial thromboplastin time 27.9%, and creatinine clearance 47.5 ml/min. The CHADS2 score was assessed as 3. Transthoracic echocardiography demonstrated a mobile thrombus of 28.6 mm  20.8 mm in the left atrium (Fig. 1). We administered 4000 units of heparin intravenously and simultaneously prescribed rivaroxaban 10 mg/day. After 5 days of rivaroxaban treatment, transthoracic echocardiography showed that the thrombus shrunk to 20.3 mm  15.6 mm (Fig. 2). After 14 days of treatment, the thrombus disappeared completely not only on transthoracic echocardiography but also on transesophageal echocardiography

Role of Cardiac Magnetic Resonance in Diagnosis and Treatment of Ball Thrombus in Left Atrium – Trust But Verify! – Case Report

“…The therapy with Rivaroxaban was safe and clinical improvement was noted. There are a few published cases of left atrial ball thrombus successfully treated with oral anticoagulation [8,11]. Decision to remove the cardiac mass by surgical way, instead of the medical management with oral anticoagulation, could expose the patient to an unnecessary surgical risk.…”

The resolution of carotid arterial thrombus by oral anticoagulation after IV thrombolysis for chemotherapy-induced stroke

“…[ 9 ] Besides its primary action of anticoagulation, its contribution to thrombolysis is postulated to be the inhibition of thrombus extension, which in turn causes unstable fibrin networks to be broken down by plasmin. [ 10 ]…”

Resolution of Internal Carotid Arterial Thrombus by the Thrombolytic Action of Dabigatran

“…Of those that did, Kaku 10 described that dabigatran induced endogenous fibrinolysis, while Nagamoto et al 11 reported dabigatran had thrombolytic action on acute preexisting intracardiac thrombus. Regarding rivaroxaban, Kato et al 12 presumed that there was promotion of fibrinolysis due to a peak and trough period, and Takasugi et al 14 reported that rivaroxaban caused a looser clot to form that is more sensitive to fibrinolytic enzyme by decreasing thrombin production. In our case, we speculate that a new thrombus formed on the unstable plaque that was originally present at the site of onset in the right internal carotid artery when oral intake of dabigatran was insufficient, and after admission, oral intake of dabigatran became regular and there was resolution of the new thrombus by a mechanism similar to that of resolution of intracardiac thrombus in previous reports.…”