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Editorial
Wagenknecht LE, West DS, Williamson DF, Yanovski SZ. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145 – 154. 22. Elliott P, Chambers JC, Zhang W, Clarke R, Hopewell JC, Peden JF, Erdmann J, Braund P, Engert JC, Bennett D, Coin L, Ashby D, Tzoulaki I, Brown IJ, Mt-Isa S, McCarthy MI, Peltonen L, Freimer NB, Farrall M, Ruokonen A, Hamsten A, Lim N, Froguel P, Waterworth DM, Vollenweider P, Waeber G, Jarvelin MR, Mooser V, Scott J, Hall AS, Schunkert H, Anand SS, Collins R, Samani NJ, Watkins H, Kooner JS. Genetic loci associated with C-reactive protein levels and risk of coronary heart disease. JAMA 2009;302:37– 48. 23. Ken-Dror G, Humphries SE, Kumari M, Kivimaki M, Drenos F. A genetic instrument for Mendelian randomization of fibrinogen. Eur J Epidemiol 2012;27:267 – 279. 24. White HD, Held C, Stewart R, Tarka E, Brown R, Davies RY, Budaj A, Harrington RA, Steg PG, Ardissino D, Armstrong PW, Avezum A, Aylward PE, Bryce A, Chen H, Chen MF, Corbalan R, Dalby AJ, Danchin N, De Winter RJ, Denchev S, Diaz R, Elisaf M, Flather MD, Goudev AR, Granger CB, Grinfeld L, Hochman JS, Husted S,
Kim HS, Koenig W, Linhart A, Lonn E, Lopez-Sendon J, Manolis AJ, Mohler ER 3rd, Nicolau JC, Pais P, Parkhomenko A, Pedersen TR, Pella D, Ramos-Corrales MA, Ruda M, Sereg M, Siddique S, Sinnaeve P, Smith P, Sritara P, Swart HP, Sy RG, Teramoto T, Tse HF, Watson D, Weaver WD, Weiss R, Viigimaa M, Vinereanu D, Zhu J, Cannon CP, Wallentin L. Darapladib for preventing ischemic events in stable coronary heart disease. N Engl J Med 2014;370:1702 – 1711. 25. Holmes MV, Exeter HJ, Folkersen L, Nelson CP, Guardiola M, Cooper JA, Sofat R, Boekholdt SM, Khaw KT, Li KW, Smith AJ, Van’t Hooft F, Eriksson P, Franco-Cereceda A, Asselbergs FW, Boer JM, Onland-Moret NC, Hofker M, Erdmann J, Kivimaki M, Kumari M, Reiner AP, Keating BJ, Humphries SE, Hingorani AD, Mallat Z, Samani NJ, Talmud PJ. Novel genetic approach to investigate the role of plasma secretory phospholipase a2 (spla2)-v isoenzyme in coronary heart disease: modified Mendelian randomization analysis using pla2g5 expression levels. Circ Cardiovasc Genet 2014;7: 144 – 150.
CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehv081 Online publish-ahead-of-print 1 April 2015
.............................................................................................................................................................................
Large protruding thrombus over left atrial appendage occlusion device successfully treated with apixaban Xavier Freixa1*, Giancarla Scalone1,2, Victoria Martı´n-Yuste1, and Ba`rbara Vidal1 1
Department of Cardiology, Thorax Institute, IDIBAPS: Institut d’Investigacions Biomediques Agust Pi i Sunyer, Hospital Clinic, Villaroel 170, Barcelona08036, Spain; and Department of Cardiology, Catholic University of Sacred Heart, Rome, Italy
2
* Corresponding author. Email: [email protected]
Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
Downloaded from by guest on June 15, 2015
This was a 61-year-old male patient with permanent non-valvular atrial fibrillation (NVAF) and CHA2DS2VASc of 5 with a relative contraindication to oral anti-coagulation (OAC) for previous intracranial haemorrhage. Left atrial appendage occlusion (LAAO) was successfully conducted with implantation of a 25-mm Amplatzer Amulet. Patient was discharged with aspirin and clopidogrel. At 3 months, trans-oesophageal echocardiography (TEE) did not show device thrombosis and clopidogrel was therefore discontinued. At 9 months, a control TEE exhibited a 25 × 23 × 1.3 mm protruding and mobile device thrombosis (Panels A and B). In our opinion, the two most plausible explanations for the thrombus formation were the doubtful treatment compliance of the patient and the presence of spontaneous echo-contrast in the left atrium. The patient was treated with apixaban 5 mg/12 h for 6 months with progressive thrombus resolution and no clinical events (Panels C and D). Considering the risk of intracranial bleeding, apixaban was stopped and aspirin was restarted again without further complications. To the best of our knowledge, this is the first report of an LAAO device thrombosis successfully treated with apixaban. Since apixaban has shown a good balance among efficacy for stroke prevention and safety for bleeding events in previous reports, this alternative might be a very valid temporary option to prevent or manage device thrombosis in patients with contraindication to conventional OAC. 2D (Panel A) and 3D (Panel B; Supplementary material online, Video S1) TEE image of the protruding thrombus attached to the LAA occlusion device. Two-dimensional TEE image of the partially and completely thrombus resolution after 3 months (Panel C) and 6 months (Panel D) therapy with apixaban, respectively.
Editorial
Wagenknecht LE, West DS, Williamson DF, Yanovski SZ. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145 – 154. 22. Elliott P, Chambers JC, Zhang W, Clarke R, Hopewell JC, Peden JF, Erdmann J, Braund P, Engert JC, Bennett D, Coin L, Ashby D, Tzoulaki I, Brown IJ, Mt-Isa S, McCarthy MI, Peltonen L, Freimer NB, Farrall M, Ruokonen A, Hamsten A, Lim N, Froguel P, Waterworth DM, Vollenweider P, Waeber G, Jarvelin MR, Mooser V, Scott J, Hall AS, Schunkert H, Anand SS, Collins R, Samani NJ, Watkins H, Kooner JS. Genetic loci associated with C-reactive protein levels and risk of coronary heart disease. JAMA 2009;302:37– 48. 23. Ken-Dror G, Humphries SE, Kumari M, Kivimaki M, Drenos F. A genetic instrument for Mendelian randomization of fibrinogen. Eur J Epidemiol 2012;27:267 – 279. 24. White HD, Held C, Stewart R, Tarka E, Brown R, Davies RY, Budaj A, Harrington RA, Steg PG, Ardissino D, Armstrong PW, Avezum A, Aylward PE, Bryce A, Chen H, Chen MF, Corbalan R, Dalby AJ, Danchin N, De Winter RJ, Denchev S, Diaz R, Elisaf M, Flather MD, Goudev AR, Granger CB, Grinfeld L, Hochman JS, Husted S,
Kim HS, Koenig W, Linhart A, Lonn E, Lopez-Sendon J, Manolis AJ, Mohler ER 3rd, Nicolau JC, Pais P, Parkhomenko A, Pedersen TR, Pella D, Ramos-Corrales MA, Ruda M, Sereg M, Siddique S, Sinnaeve P, Smith P, Sritara P, Swart HP, Sy RG, Teramoto T, Tse HF, Watson D, Weaver WD, Weiss R, Viigimaa M, Vinereanu D, Zhu J, Cannon CP, Wallentin L. Darapladib for preventing ischemic events in stable coronary heart disease. N Engl J Med 2014;370:1702 – 1711. 25. Holmes MV, Exeter HJ, Folkersen L, Nelson CP, Guardiola M, Cooper JA, Sofat R, Boekholdt SM, Khaw KT, Li KW, Smith AJ, Van’t Hooft F, Eriksson P, Franco-Cereceda A, Asselbergs FW, Boer JM, Onland-Moret NC, Hofker M, Erdmann J, Kivimaki M, Kumari M, Reiner AP, Keating BJ, Humphries SE, Hingorani AD, Mallat Z, Samani NJ, Talmud PJ. Novel genetic approach to investigate the role of plasma secretory phospholipase a2 (spla2)-v isoenzyme in coronary heart disease: modified Mendelian randomization analysis using pla2g5 expression levels. Circ Cardiovasc Genet 2014;7: 144 – 150.
CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehv081 Online publish-ahead-of-print 1 April 2015
.............................................................................................................................................................................
Large protruding thrombus over left atrial appendage occlusion device successfully treated with apixaban Xavier Freixa1*, Giancarla Scalone1,2, Victoria Martı´n-Yuste1, and Ba`rbara Vidal1 1
Department of Cardiology, Thorax Institute, IDIBAPS: Institut d’Investigacions Biomediques Agust Pi i Sunyer, Hospital Clinic, Villaroel 170, Barcelona08036, Spain; and Department of Cardiology, Catholic University of Sacred Heart, Rome, Italy
2
* Corresponding author. Email: [email protected]
Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
Downloaded from by guest on June 15, 2015
This was a 61-year-old male patient with permanent non-valvular atrial fibrillation (NVAF) and CHA2DS2VASc of 5 with a relative contraindication to oral anti-coagulation (OAC) for previous intracranial haemorrhage. Left atrial appendage occlusion (LAAO) was successfully conducted with implantation of a 25-mm Amplatzer Amulet. Patient was discharged with aspirin and clopidogrel. At 3 months, trans-oesophageal echocardiography (TEE) did not show device thrombosis and clopidogrel was therefore discontinued. At 9 months, a control TEE exhibited a 25 × 23 × 1.3 mm protruding and mobile device thrombosis (Panels A and B). In our opinion, the two most plausible explanations for the thrombus formation were the doubtful treatment compliance of the patient and the presence of spontaneous echo-contrast in the left atrium. The patient was treated with apixaban 5 mg/12 h for 6 months with progressive thrombus resolution and no clinical events (Panels C and D). Considering the risk of intracranial bleeding, apixaban was stopped and aspirin was restarted again without further complications. To the best of our knowledge, this is the first report of an LAAO device thrombosis successfully treated with apixaban. Since apixaban has shown a good balance among efficacy for stroke prevention and safety for bleeding events in previous reports, this alternative might be a very valid temporary option to prevent or manage device thrombosis in patients with contraindication to conventional OAC. 2D (Panel A) and 3D (Panel B; Supplementary material online, Video S1) TEE image of the protruding thrombus attached to the LAA occlusion device. Two-dimensional TEE image of the partially and completely thrombus resolution after 3 months (Panel C) and 6 months (Panel D) therapy with apixaban, respectively.
