Rivaroxaban as an effective alternative to warfarin in a patient with atrial fibrillation, thrombophilia, and left atrial appendage thrombus: a case report

Abstract

BackgroundAtrial fibrillation is the most common cardiac arrhythmia. It is responsible for up to 20% of all ischemic strokes. Rate control and anticoagulation are crucial for atrial fibrillation management and stroke prevention.Case presentationWe present the case of an 84-year-old Italian woman with a left atrial appendage thrombus that developed despite her use of anticoagulant therapy with warfarin for a previous pulmonary embolism. She had atrial fibrillation and heterozygosity for both factor V Leiden and methylenetetrahydrofolate reductase C677T mutation, thus creating resistance to activated protein C. Anticoagulant therapy was switched to heparin for 1 week and then to rivaroxaban. After 3 months of rivaroxaban use, the thrombus disappeared.ConclusionsThis case raises the issue of the ineffectiveness of warfarin therapy in complex cases involving particular thrombophilic conditions and the possibility of using rivaroxaban as a safe and effective alternative.

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

“…The treatment was then switched to clopidogrel, which still did not lead to a satisfactory resolution of the thrombus. Contrary to current AHA guidelines, which do not recommend NOAC administration in patients with biological heart valves, there have been several cases of patients with thrombi in the enlarged LA or LAA treated with NOAC described in the current literature in whose treatment with NOAC resulted in the dissolution of thrombi [16][17][18]. In our case, NOAC (specifically rivaroxaban) was used "off-label" and even combined with clopidogrel, which finally lead to the partial dissolution of the thrombus.…”

Case Report: A Rare Case of Biatrial Thrombus in the Absence of Interatrial Shunt

“…Atrial thrombi are most commonly detected in association with atrial arrythmias, with AF being the most common type [3,6]. When a patient presents with an atrial thrombus, while in SR, the etiology of this finding must be further investigated.…”

Atrial fibrillation and thrombophilia. DOAC as a valid alternative? A clinical case

“…One may speculate that, in this patient, resistance to protein C could have promoted a paradoxical pro-coagulant effect of warfarin conversely to its therapeutic anticoagulant effect. 3 Warfarin, as a vitamin K antagonist (VKA), works indirectly on various coagulation factors and also on protein C, that has a signifi cant role in coagulation cascade. 24 A TTR almost in the range allows to exclude other possible causes but some oscillations could explain, in a case of thrombophilia, occurrence of thrombotic phenomena.…”

“…1 However, management could be challenging in particular situations such as thrombophilia, a condition predisposing to a higher risk of thromboembolism, 2 sometimes leading to resistance to vitamin K antagonists (VKAs). 3,4 Direct oral anticoagulants (DOACs) can be a therapeutic option for stroke prevention in patients with non-valvular AF. 1 Among these, edoxaban, a factor--Xa inhibitor, has demonstrated to be non-inferior to warfarin in terms of effi cacy and safety.…”