The use of Apixaban for the treatment of an LV thrombus

Abstract

SummaryA 42-year-old male was admitted with shortness of breath secondary to suspected heart failure and chest infection. An echocardiogram revealed a dilated and impaired left ventricle; ejection fraction 29%, with a large, mobile thrombus within the left ventricular apex. Due to the presence of liver dysfunction, vitamin K antagonists were deemed inappropriate; thus, the decision was taken to use the novel anticoagulation agent Apixaban. After 6 days of receiving Apixaban, a cardiac magnetic resonance scan was preformed, which showed complete resolution of the LV apical thrombus.Learning points:Patients with a dilated and impaired LV are at an increased risk of developing LV thrombus.A large and mobile LV thrombus is associated with an increased risk of embolic events.Vitamin K antagonists (VKAs) are often the first-line therapy for LV thrombus; however, these may be inappropriate in some patients.NOACs are advantageous in comparison to VKAs and are used to treat: non-valvular atrial fibrillation, pulmonary embolisms and used in the prevention of recurrent deep vein thrombosis in adults.To date, NOACs are not licensed for the treatment of an LV thrombus; however, there are growing evidence whereby there use has shown promise in reducing the risk of embolic events and demonstrate rapid reduction in size/full resolution of an LV thrombus.Large, randomised research trials comparing NOACs and VKAs in the treatment of LV thrombus are needed, which may lead to a change in standard clinical practice that could benefit patients.

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

“…36,37 Evidence supporting the efficacy of DOACs in treatment of LVT for apixaban, rivaroxaban, and dabigatran had previously been limited to case reports and single-armed case series. [16][17][18][19][20][21][22][23][24][25][26][27][28][29] The largest systematic review evaluating the clinical question of DOAC for LVT was performed by Kajy et al, and found high efficacy of thrombus resolution with low bleeding rates in data spanning 30 articles and 41 patients. 38 However, recently, a few studies including our own have examined the efficacy and safety of DOAC in the off-label treatment of LVT as compared to the current standard of care, VKA.…”

“…Previously, evidence for the use of DOACs in the setting of LVT have been confined to case reports and case series, and there remain limited comparative studies of DOACs versus VKA. 16 -29…”

“…Previously, evidence for the use of DOACs in the setting of LVT have been confined to case reports and case series, and there remain limited comparative studies of DOACs versus VKA. [16][17][18][19][20][21][22][23][24][25][26][27][28][29] The aim of our study is to add to the current body of literature to assess the safety and efficacy of DOACs compared to VKA for the treatment of LVT in 2 large academic hospitals. We further pooled data of our study with existing studies and performed a meta-analysis to examine the effect of DOAC versus VKA in the treatment of LVT.…”

The concoction of cancer, catheter, and intracardiac clot: a case report describing a potential treatment strategy

“…There have also been several case reports describing the effectiveness of DOACs in the treatment of left ventricular (LV) thrombus. 9 , 10 However, the literature describing the use of DOACs to treat right-sided thrombus is sparse and large-scale randomized control trials (RCT) are lacking in this area. Even the current recommendations to use oral vitamin K antagonists for left-sided intracardiac clots are largely based on observational studies and not RCTs, as RCTs would be rather difficult to conduct in this cohort.…”

“…There were no clear guidelines on how to manage this unique situation and the patient preferred an oral anticoagulant that did not require frequent monitoring. Due to the efficacy and safety profile of apixaban, 17 and its success in treating intracardiac thrombus, 9 , 10 we decided to treat our patient with apixaban. After discussing the potential risks and benefits, the patient was started on apixaban 10 mg twice daily initially for 7 days and then 5 mg a day thereafter.…”