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Sadie Bennett, Duwarakan Satchithananda and Gareth Law

Summary

A 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.