Effects of novel oral anticoagulants on left atrial and left atrial appendage thrombi: an appraisal

Marsico, Fabio; Cecere, Milena; Parente, António; Paolillo, Stefania; Martino, Fabiana De; Dellegrottaglie, Santo; Trimarco, Bruno; Filardi, Pasquale Perrone

doi:10.1007/s11239-016-1421-9

Cited by 9 publications

(8 citation statements)

References 54 publications

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“…Until recently, European guidelines recommended the use of vitamin K antagonists for at least 3 weeks to dissolve thrombi in the LAA and long-term therapy for persistent thrombin [ 27 ]. In the last years, first case reports and later smaller studies were published suggesting the usage of NOAC as a possible therapeutic option for thrombi or SEC [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

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Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants

et al. 2021

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Background Thrombi and spontaneous echo contrast (SEC) in the left atrial appendage (LAA) are associated with thromboembolic events and poor prognosis. There are very few data on long-term outcome, especially with the use of direct acting anticoagulants (DOAC). Methods In this retrospective study, all transoesophageal echocardiographies performed at a tertiary care university hospital from 2015 to 2020 were analyzed. All patients with thrombus or SEC in the LAA were included. Medical history, laboratory, echocardiographic parameters and medication at discharge were documented. The primary endpoint of the study was a composite endpoint (all-cause mortality, non-fatal stroke or transient ischaemic attack [TIA], non-fatal systemic embolization, non-fatal major bleeding and non-fatal myocardial infarction). Results Of a total of 4062 transoesophageal echocardiographies, thrombi were detected in 51 patients (1.2%) and SEC in 251 patients (6.2%). These patients formed the final study cohort (n = 302). During a mean follow-up period of 956 ± 663 days, 87 patients (29%) suffered the primary point. The following baseline characteristics predicted the primary endpoint: age, haemoglobin, a previous coronary artery bypass grafting, dialysis and choice of anticoagulation. Prescription of apixaban at discharge was associated with lower rate of adverse events (hazard ratio 0.564, confidence interval 0.331–0.960; p = 0.035) while prescription of dabigatran was associated with higher rate of adverse events (hazard ratio 3.091, confidence interval 1.506–6.347; p = 0.002). Conclusion Even in the DOAC era, the occurrence of thrombus or SEC in the LAA is associated with a high rate of MACCE. Our study suggests that the choice of DOAC therapy may have an impact on long-term survival. Graphic abstract

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Section: Discussionmentioning

confidence: 99%

“…About 10 years ago, the direct acting anticoagulants (DOACs) were introduced for the prophylaxis of thromboembolic events in patients with AF [ 11 – 14 ]. Despite the partial lack of data from prospective randomised controlled trials [ 15 ], DOACs are used in many centers for the treatment of thrombi in the LAA [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants

et al. 2021

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“…Little is known, however, about what kind of action should be undertaken if patient is diagnosed with thrombus in LAA despite apparently correct chronic OAC treatment [23]. Published data is scarce and limited mainly to small case series or case reports [9,[24][25][26].…”

Section: Introductionmentioning

confidence: 99%

The Comparative Effectiveness and Safety of Different Anticoagulation Strategies for Treatment of Left Atrial Appendage Thrombus in the Setting of Chronic Anticoagulation for Atrial Fibrillation or Flutter

Kołakowski

Farkowski

Pytkowski

et al. 2021

Cardiovasc Drugs Ther

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Purpose To compare effectiveness of different treatments for atrial fibrillation (AF) patients who were scheduled for cardioversion (CV) or ablation (CA) presenting with left atrium appendage (LAA) thrombus despite chronic oral anticoagulation therapy (OAC). Methods This was a retrospective cohort study. We analyzed 2014–2019 medical records of patients scheduled for CV or CA of AF who were diagnosed with LAA thrombus despite optimal OAC and had a follow-up transesophageal echocardiogram (TOE). Changes in treatment were divided into the following groups: switch to a drug with different mechanism of action, switch to a drug with similar mechanism of action, initiation of combination therapy, or deliberate no change in treatment. Patients with contraindications to non-vitamin K antagonists were excluded from the analysis. Results We analyzed data of 129 patients comprising 181 cycles of treatment. The overall effectiveness of LAA thrombus dissolution was 51.9% regardless of the number of cycles and 42.6% for the first cycle of treatment. Any change of treatment was more effective than deliberate no change—OR 2.97 [95% CI: 1.07–8.25], P = 0.031, but no particular strategy seemed to be more effective than the other. Left atrium area (OR 0.908 [95% CI: 0.842–0.979]) and number of treatment cycles (OR 0.457 [95% CI: 0.239–0.872]) were both adversely related to thrombus resolution. There was one ischemic and three bleeding adverse events during the treatment. Conclusion LAA thrombus resolution in patients already on OAC may require a change of previous OAC treatment but the overall effectiveness of dissolution seems to be about 50%.

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“…It is well known that AF is the most common sustained cardiac arrhythmia and predisposes the patient to an increased risk of thromboembolic events, with the most common location of thrombi being in the LAA [13]. Dilatation of the LA is associated with disturbances of blood flow/blood stasis and the formation of a thrombus.…”

Section: Discussionmentioning

confidence: 99%

Reccurent thrombus in the gigantic left atrium during effective anticoagulant therapy: case report

Masárová

Novák

Pešl

et al. 2020

BMC Cardiovasc Disord

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Background: Gigantic left atrium is defined in the current literature as an excessive dilatation of the left atrium above 65mm. Chronic mitral valve disease is associated with the development of thrombus in the left atrium in up to 19% of all cases of mitral insufficiency and appropriate treatment must be initiated to prevent thromboembolic events. In order to diagnose thrombi in the left atrium or left atrial appendage, various imaging methods may be used, including cardiac magnetic resonance. Case presentation: The case report describes a 73-year-old male who developed recurrent sessile thrombus on the posterior wall of the gigantic left atrium. A large thrombus was first detected following mitral valve surgery despite effective vitamin K antagonist anticoagulation therapy. Echocardiography and cardiac magnetic resonance were used within the diagnostic procedure and to monitor the treatment outcomes. Cardiac magnetic resonance was shown to be beneficial as it provided a more precise description of the intra-atrial masses located on the posterior left atrial wall, and in such situations, is of greater benefit than standard echocardiography. This led to the surgical removal of the intra-atrial mass; nevertheless, it was quickly followed by the recurrence of the thrombus. The anticoagulant therapy was adjusted and fortified by the introduction of acetylsalicylic acid and sequentially clopidogrel, but this also did not resolve the thrombus formation. Finally, employing a combination of rivaroxaban and clopidogrel resulted in partial thrombus regression. Therefore, various pathophysiological aspects of thrombus formation and used anticoagulation strategies are discussed. Conclusions: We describe a unique case of a recurrent thrombus located on the posterior wall of the gigantic left atrium. Cardiac magnetic resonance was shown to be beneficial in providing a more precise description of the intra-atrial masses located on the posterior left atrial wall as compared to standard echocardiographic examination. Development of a thrombus after mitral valve surgery despite effective anticoagulant therapy and its final resolution by introducing a combination of rivaroxaban and clopidogrel highlights the complex etiopathogenesis of thrombus formation. This supports the potential use of this combination in tailoring an individual personalized therapy for patients with recurrent atrial thrombi.

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Effects of novel oral anticoagulants on left atrial and left atrial appendage thrombi: an appraisal

Cited by 9 publications

References 54 publications

Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants

Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants

The Comparative Effectiveness and Safety of Different Anticoagulation Strategies for Treatment of Left Atrial Appendage Thrombus in the Setting of Chronic Anticoagulation for Atrial Fibrillation or Flutter

Reccurent thrombus in the gigantic left atrium during effective anticoagulant therapy: case report

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