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Resolution of left ventricular thrombus by rivaroxaban Miriam Padilla Pérez*,1, Daniel Salas Bravo1, Juan Arsenio Garcelán Trigo2, Eduardo Vazquez Ruiz de Castroviejo1, Javier Torres Llergo1, Cristóbal Lozano Cabezas1 & Juan Carlos Fernández Guerrero1
ABSTRACT: Intracardiac thrombus is a potentially life-threatening condition, with a high risk of embolic complications. Although vitamin K antagonists have been traditionally used for the treatment of intracardiac thrombus, they have relevant disadvantages that limit their use. Rivaroxaban is a once daily oral anticoagulant, currently indicated for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, and for the prevention and treatment of venous thromboembolism. We present the case of a 78-year-old man with nonvalvular atrial fibrillation, heart failure and creatinine clearance of 40 ml/min, anticoagulated with rivaroxaban 15 mg/day as the patient had very difficult access to hematologic controls. The transthoracic echocardiogram showed dilated left ventricle, severe left ventricular dysfunction and two images of thrombus, which disappeared after 4 weeks of treatment with rivaroxaban. To our knowledge, this is the first case reported regarding the resolution of left ventricular thrombosis with rivaroxaban. Background Intracardiac thrombus is a potentially life-threatening condition, with a high risk of embolic complications. Despite that, the information available about its treatment is scarce. In fact, no randomized clinical trials have been specifically performed. Moreover, although vitamin K antagonists (VKA) have been traditionally used for the treatment of intracardiac thrombus, they have relevant limitations [1] . New oral anticoagulants have several advantages over warfarin, but their efficacy and safety in this context is unknown.
KEYWORDS
• atrial fibrillation • heart failure • intracardiac
thrombus rivaroxaban • vitamin K antagonists
Clinical case ●●Presentation of case
We present the case of a 78-year-old man with no previous history of heart disease who was admitted in hospital for congestive heart failure. The ECG showed atrial fibrillation (first known episode) and complete left bundle branch block. Creatinine clearance was calculated at 40 ml/min. ●●Initial diagnosis/assessment
Carvedilol 6.25 mg twice daily (b.i.d), enalapril 10 mg b.i.d and intravenous furosemide were initiated for the heart failure episode. The patient was reluctant to be prescribed VKA for stroke prevention in the context of atrial fibrillation and he referred to very difficult access to hematologic controls, so 15 mg/day rivaroxaban was initiated. The transthoracic echocardiogram showed dilated left ventricle, severe left ventricular dysfunction and two images of thrombus, one small in the basal inferior segment (Figure 1A) and one bigger in the apex (Figures 1B & 1C) . Cardiology Department, Complejo Hospitalario de Jaén, Jaén, Spain Radiology Department, Hospital San Agustín de Linares, Linares, Spain *Author for correspondence: [email protected] 1 2
10.2217/FCA.14.12 © 2014 Future Medicine Ltd
Future Cardiol. (2014) 10(3), 333–336
part of
ISSN 1479-6678
333
Case Report Padilla Pérez, Salas Bravo, Garcelán Trigo et al. ●●Evolution
The patient was discharged after clinical stabilization and another echocardiogram, after 4 weeks of treatment, was programmed, which showed resolution of both thrombi (Figure 2A–D) . Patient was asymptomatic, showed no signs of systemic or central embolism and remained with the same treatment. Discussion & conclusion Many conditions increase the risk of intracardiac thrombus in the left ventricle (dilated cardiomyopathy, severe left ventricular dysfunction, myocarditis, myocardial infarction or ventricular aneurysm). Transthoracic echocardiogram is usually used for diagnosis. The use of ultrasound contrast media is sometimes necessary to enhance its diagnostic accuracy [1] , but contraindicated in the context of acute heart failure. Despite the lack of evidence, the use of VKA for up to 6 months is recommended in patients with myocardial infarction and mural thrombi, with repeated imaging after 3 months
of therapy [2] . Rivaroxaban is an oral direct factor Xa inhibitor, taken once daily, currently indicated for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, and for the prevention and treatment of venous thromboembolism [3] . It has been reported that rivaroxaban is associated with successful treatment of giant left atrial appendage thrombus and acute portal vein thrombosis [4,5] . To our knowledge, this is the first case reported regarding the resolution of left ventricular thrombosis with rivaroxaban. Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Editorial Asistance was provided by Content Ed Net. This assistance was funded by Bayer.
A
B
C
Figure 1. Transthoracic echocardiogram. (A) Thrombus in the basal inferior segment of left ventricle (short axis view); (B) and (C) thrombus in the apex (apical four chamber view).
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Future Cardiol. (2014) 10(3)
future science group
Resolution of left ventricular thrombus by rivaroxaban
A
B
C
D
Case Report
Figure 2. Resolution of both thrombi. (A) and (C) Short axis view, without and with ultrasound contrast media, respectively. (B) and (D) Apical four chamber view, without and with ultrasound contrast media, respectively.
EXECUTIVE SUMMARY Background ●●
Intracardiac thrombus is a potentially life-threatening condition, with a high risk of embolic complications.
●●
Although vitamin K antagonists have been traditionally used for the treatment of intracardiac thrombus, they have relevant disadvantages that limit their use.
●●
New oral anticoagulants have several advantages over warfarin, but their efficacy and safety in this context is unknown.
Clinical case ●●
We present the case of a 78-year-old man with nonvalvular atrial fibrillation, heart failure and creatinine clearance of 40 ml/min, anticoagulated with rivaroxaban 15 mg/day as patient had very difficult access to hematologic controls.
●●
The transthoracic echocardiogram showed dilated left ventricle, severe left ventricular dysfunction and two images of thrombus, which disappeared after 4 weeks of treatment with rivaroxaban.
Discussion & conclusion ●●
Many conditions increase the risk of intracardiac thrombus in the left ventricle (dilated cardiomyopathy, severe left ventricular dysfunction, myocarditis, myocardial infarction or ventricular aneurysm).
●●
Despite the lack of evidence, the use of vitamin K antagonists is recommended in patients with myocardial infarction and mural thrombi for up to 6 months, with repeated imaging after 3 months of therapy.
●●
Rivaroxaban is a once daily oral anticoagulant, currently indicated for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, and for the prevention and treatment of venous thromboembolism.
●●
To our knowledge, this is the first case reported regarding the resolution of left ventricular thrombosis with rivaroxaban.
future science group
www.futuremedicine.com
335
Case Report Padilla Pérez, Salas Bravo, Garcelán Trigo References Papers of special note have been highlighted as: • of interest 1
Egolum UO, Stover DG, Anthony R, Wasserman AM, Lenihan D, Damp JB. Intracardiac thrombus: diagnosis, complications and management. Am. J. Med. Sci. 345(5), 391–395 (2013).
2
Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology; Steg PG, James SK et al. ESC Guidelines for the management of acute myocardial infarction
336
3
4
in patients presenting with ST-segment elevation. Eur. Heart. J. 33(20), 2569–2619 (2012).
• Reports a clinical case of resolution of giant left atrial appendage thrombus with rivaroxaban.
European Medicines Agency. Xarelto®, Summary of product characteristics. www.ema.europa.eu/docs/en_GB/ document_library/EPAR_-_Product_ Information/human/000944/ WC500057108.pdf
5
Hammerstingl C, Potzsch B, Nickenig G. Resolution of giant left atrial appendage thrombus with rivaroxaban. Thromb. Haemost. 109(4), 583–584 (2013).
Future Cardiol. (2014) 10(3)
Pannach S, Babatz J, Beyer-Westendorf J. Successful treatment of acute portal vein thrombosis with rivaroxaban. Thromb. Haemost. 110(4), 626–627 (2013).
• Reports a clinical case of successful treatment of acute portal vein thrombosis with rivaroxaban.
future science group
Resolution of left ventricular thrombus by rivaroxaban Miriam Padilla Pérez*,1, Daniel Salas Bravo1, Juan Arsenio Garcelán Trigo2, Eduardo Vazquez Ruiz de Castroviejo1, Javier Torres Llergo1, Cristóbal Lozano Cabezas1 & Juan Carlos Fernández Guerrero1
ABSTRACT: Intracardiac thrombus is a potentially life-threatening condition, with a high risk of embolic complications. Although vitamin K antagonists have been traditionally used for the treatment of intracardiac thrombus, they have relevant disadvantages that limit their use. Rivaroxaban is a once daily oral anticoagulant, currently indicated for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, and for the prevention and treatment of venous thromboembolism. We present the case of a 78-year-old man with nonvalvular atrial fibrillation, heart failure and creatinine clearance of 40 ml/min, anticoagulated with rivaroxaban 15 mg/day as the patient had very difficult access to hematologic controls. The transthoracic echocardiogram showed dilated left ventricle, severe left ventricular dysfunction and two images of thrombus, which disappeared after 4 weeks of treatment with rivaroxaban. To our knowledge, this is the first case reported regarding the resolution of left ventricular thrombosis with rivaroxaban. Background Intracardiac thrombus is a potentially life-threatening condition, with a high risk of embolic complications. Despite that, the information available about its treatment is scarce. In fact, no randomized clinical trials have been specifically performed. Moreover, although vitamin K antagonists (VKA) have been traditionally used for the treatment of intracardiac thrombus, they have relevant limitations [1] . New oral anticoagulants have several advantages over warfarin, but their efficacy and safety in this context is unknown.
KEYWORDS
• atrial fibrillation • heart failure • intracardiac
thrombus rivaroxaban • vitamin K antagonists
Clinical case ●●Presentation of case
We present the case of a 78-year-old man with no previous history of heart disease who was admitted in hospital for congestive heart failure. The ECG showed atrial fibrillation (first known episode) and complete left bundle branch block. Creatinine clearance was calculated at 40 ml/min. ●●Initial diagnosis/assessment
Carvedilol 6.25 mg twice daily (b.i.d), enalapril 10 mg b.i.d and intravenous furosemide were initiated for the heart failure episode. The patient was reluctant to be prescribed VKA for stroke prevention in the context of atrial fibrillation and he referred to very difficult access to hematologic controls, so 15 mg/day rivaroxaban was initiated. The transthoracic echocardiogram showed dilated left ventricle, severe left ventricular dysfunction and two images of thrombus, one small in the basal inferior segment (Figure 1A) and one bigger in the apex (Figures 1B & 1C) . Cardiology Department, Complejo Hospitalario de Jaén, Jaén, Spain Radiology Department, Hospital San Agustín de Linares, Linares, Spain *Author for correspondence: [email protected] 1 2
10.2217/FCA.14.12 © 2014 Future Medicine Ltd
Future Cardiol. (2014) 10(3), 333–336
part of
ISSN 1479-6678
333
Case Report Padilla Pérez, Salas Bravo, Garcelán Trigo et al. ●●Evolution
The patient was discharged after clinical stabilization and another echocardiogram, after 4 weeks of treatment, was programmed, which showed resolution of both thrombi (Figure 2A–D) . Patient was asymptomatic, showed no signs of systemic or central embolism and remained with the same treatment. Discussion & conclusion Many conditions increase the risk of intracardiac thrombus in the left ventricle (dilated cardiomyopathy, severe left ventricular dysfunction, myocarditis, myocardial infarction or ventricular aneurysm). Transthoracic echocardiogram is usually used for diagnosis. The use of ultrasound contrast media is sometimes necessary to enhance its diagnostic accuracy [1] , but contraindicated in the context of acute heart failure. Despite the lack of evidence, the use of VKA for up to 6 months is recommended in patients with myocardial infarction and mural thrombi, with repeated imaging after 3 months
of therapy [2] . Rivaroxaban is an oral direct factor Xa inhibitor, taken once daily, currently indicated for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, and for the prevention and treatment of venous thromboembolism [3] . It has been reported that rivaroxaban is associated with successful treatment of giant left atrial appendage thrombus and acute portal vein thrombosis [4,5] . To our knowledge, this is the first case reported regarding the resolution of left ventricular thrombosis with rivaroxaban. Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Editorial Asistance was provided by Content Ed Net. This assistance was funded by Bayer.
A
B
C
Figure 1. Transthoracic echocardiogram. (A) Thrombus in the basal inferior segment of left ventricle (short axis view); (B) and (C) thrombus in the apex (apical four chamber view).
334
Future Cardiol. (2014) 10(3)
future science group
Resolution of left ventricular thrombus by rivaroxaban
A
B
C
D
Case Report
Figure 2. Resolution of both thrombi. (A) and (C) Short axis view, without and with ultrasound contrast media, respectively. (B) and (D) Apical four chamber view, without and with ultrasound contrast media, respectively.
EXECUTIVE SUMMARY Background ●●
Intracardiac thrombus is a potentially life-threatening condition, with a high risk of embolic complications.
●●
Although vitamin K antagonists have been traditionally used for the treatment of intracardiac thrombus, they have relevant disadvantages that limit their use.
●●
New oral anticoagulants have several advantages over warfarin, but their efficacy and safety in this context is unknown.
Clinical case ●●
We present the case of a 78-year-old man with nonvalvular atrial fibrillation, heart failure and creatinine clearance of 40 ml/min, anticoagulated with rivaroxaban 15 mg/day as patient had very difficult access to hematologic controls.
●●
The transthoracic echocardiogram showed dilated left ventricle, severe left ventricular dysfunction and two images of thrombus, which disappeared after 4 weeks of treatment with rivaroxaban.
Discussion & conclusion ●●
Many conditions increase the risk of intracardiac thrombus in the left ventricle (dilated cardiomyopathy, severe left ventricular dysfunction, myocarditis, myocardial infarction or ventricular aneurysm).
●●
Despite the lack of evidence, the use of vitamin K antagonists is recommended in patients with myocardial infarction and mural thrombi for up to 6 months, with repeated imaging after 3 months of therapy.
●●
Rivaroxaban is a once daily oral anticoagulant, currently indicated for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, and for the prevention and treatment of venous thromboembolism.
●●
To our knowledge, this is the first case reported regarding the resolution of left ventricular thrombosis with rivaroxaban.
future science group
www.futuremedicine.com
335
Case Report Padilla Pérez, Salas Bravo, Garcelán Trigo References Papers of special note have been highlighted as: • of interest 1
Egolum UO, Stover DG, Anthony R, Wasserman AM, Lenihan D, Damp JB. Intracardiac thrombus: diagnosis, complications and management. Am. J. Med. Sci. 345(5), 391–395 (2013).
2
Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology; Steg PG, James SK et al. ESC Guidelines for the management of acute myocardial infarction
336
3
4
in patients presenting with ST-segment elevation. Eur. Heart. J. 33(20), 2569–2619 (2012).
• Reports a clinical case of resolution of giant left atrial appendage thrombus with rivaroxaban.
European Medicines Agency. Xarelto®, Summary of product characteristics. www.ema.europa.eu/docs/en_GB/ document_library/EPAR_-_Product_ Information/human/000944/ WC500057108.pdf
5
Hammerstingl C, Potzsch B, Nickenig G. Resolution of giant left atrial appendage thrombus with rivaroxaban. Thromb. Haemost. 109(4), 583–584 (2013).
Future Cardiol. (2014) 10(3)
Pannach S, Babatz J, Beyer-Westendorf J. Successful treatment of acute portal vein thrombosis with rivaroxaban. Thromb. Haemost. 110(4), 626–627 (2013).
• Reports a clinical case of successful treatment of acute portal vein thrombosis with rivaroxaban.
future science group
