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Dabigatran for left ventricular thrombus
indian heart journal 67 (2015) 495–496
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Images in Cardiology
Dabigatran for left ventricular thrombus Satishkumar Kolekar c,*, Chandrashekhar Munjewar b, Satyavan Sharma a a
Professor and Head of Cardiology, Department of Cardiology, Bombay Hospital Institute of Medical Sciences, Bombay Hospital, 12, New Marine Lines, Mumbai, Maharashtra 400 020, India b Clinical Associate, Department of Cardiology, Bombay Hospital Institute of Medical Sciences, Bombay Hospital, 12, New Marine Lines, Mumbai, Maharashtra 400 020, India c Senior Registrar, Department of Cardiology, Bombay Hospital Institute of Medical Sciences, Bombay Hospital, 12, New Marine Lines, Mumbai, Maharashtra 400 020, India
article info
abstract
Article history:
Male patient in dilated phase of hypertrophic cardiomyopathy had multiple hospitalizations
Received 9 July 2014
during the past 2 years either due to congestive heart failure, stroke, scar epilepsy, or atrial
Accepted 4 June 2015
fibrillation and ventricular tachycardia. Medication included evidence based therapy for
Available online 8 August 2015
heart failure, cordarone and warfarin. Anticoagulation had to be discontinued due to marked fluctuations in INR. Transthoracic Echocardiography (TTE) revealed a mobile mass in the left
Keywords:
ventricle. He was treated with Dabigatran 110 mg twice a day for 4 months without any
Mass
bleeding or embolic episode and complete resolution of thrombus.
Left ventricle
Dabigatran is a reversible direct thrombin inhibitor and currently approved for the preven-
Dabigatran
tion of thromboembolic episodes in non-valvar atrial fibrillation. This case demonstrates
Thrombolytic
possible thrombolytic properties of dabigatran in resolution of left ventricular thrombus. # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
A 61-year-old male patient in dilated phase of hypertrophic cardiomyopathy had multiple hospitalizations during the past 2 years either due to congestive heart failure, stroke, scar epilepsy, or atrial fibrillation and ventricular tachycardia. He also had diabetes mellitus and hypertension. The 'CHADS2' score was 5. His creatinine clearance was 71.31 ml/min. Medication included ramipril, carvedilol, furosemide, aldactone, cordarone, warfarin, phenytoin sodium, and insulin. Anticoagulation had to be discontinued due to marked fluctuations in International Normalized Ratio (INR). Cordarone and phenytoin would have contributed to the INR variations. During recent hospitalization for aggravation of heart failure, chest X-ray demonstrated cardiomegaly and pulmonary congestion. Transthoracic Echocardiography (TTE)
revealed a mobile mass measuring 2.30 1.16 cm2 in the left ventricle (Panel A, video 1). He was treated with Dabigatran 110 mg twice a day for the past 4 months without any bleeding or embolic episode and resulted in complete resolution of thrombus (Panel B, video 2) (Fig. 1). Dabigatran is a reversible direct thrombin inhibitor and is currently approved for the prevention of thromboembolic episodes in non-valvar atrial fibrillation1 and in those undergoing orthopedic surgery.2 The effects of novel oral anticoagulants on intracardiac thrombi have not been elucidated. There are scattered reports of their use in left atrial thrombus with variable response ranging from increase in its size to resolution of clot.3,4 Its potential to inhibit thrombin bound to fibrin and fibrin degradation products might be
* Corresponding author at: C/O Dr. Satyavan Sharma, Room no. 104, 1st Floor, New Wing, Bombay Hospital, New Marine Lines, Mumbai, Maharashtra 400020, India. Tel.: +91 22 22054532; fax: +91 22 22064533. E-mail address: [email protected] (S. Kolekar). http://dx.doi.org/10.1016/j.ihj.2015.06.010 0019-4832/# 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
496
[(Fig._1)TD$IG]
indian heart journal 67 (2015) 495–496
Fig. 1 – Transthoracic Echocardiography images; Panel A: mobile thrombus 2.3 1.16 cm2 in left ventricle; Panel B: complete resolution of thrombus after treatment with Dabigatran.
responsible for thrombolysis in this patient. As an alternate hypothesis, possibility of spontaneous clot lysis cannot be excluded. The short (4 months) follow-up in this case demonstrates possible thrombolytic properties of Dabigatran in resolution of left ventricular thrombus. This observation needs to be confirmed by larger and long-term data.
Conflicts of interest The authors have none to declare.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ihj.2015.06.010.
references
1. Camm AJ, Lip GY, De Caterina R, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the ESC Guidelines for the 2010 management of atrial fibrillation [34_TD$IF]developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;[35_TD$IF] 33:2719–2747. 2. Garza R, Huo MH. Thromboembolic prophylaxis in orthopedic surgery using dabigatran: an oral direct thrombin inhibitor. Expert Rev Cardiovasc Ther. 2012;[36_TD$IF]10:423–427. 3. Luis SA, Poon K, Luis C, et al. Massive left atrial thrombus in a patient with rheumatic mitral stenosis and atrial fibrillation while anticoagulated with dabigatran. Circ Cardiovasc Imaging. 2013;[37_TD$IF]6:491–492. 4. Morita S, Ajiro Y, Uchida Y, Iwade K. Dabigatran for left atrial thrombus. Eur Heart J. 2013;[35_TD$IF][834:2745.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Images in Cardiology
Dabigatran for left ventricular thrombus Satishkumar Kolekar c,*, Chandrashekhar Munjewar b, Satyavan Sharma a a
Professor and Head of Cardiology, Department of Cardiology, Bombay Hospital Institute of Medical Sciences, Bombay Hospital, 12, New Marine Lines, Mumbai, Maharashtra 400 020, India b Clinical Associate, Department of Cardiology, Bombay Hospital Institute of Medical Sciences, Bombay Hospital, 12, New Marine Lines, Mumbai, Maharashtra 400 020, India c Senior Registrar, Department of Cardiology, Bombay Hospital Institute of Medical Sciences, Bombay Hospital, 12, New Marine Lines, Mumbai, Maharashtra 400 020, India
article info
abstract
Article history:
Male patient in dilated phase of hypertrophic cardiomyopathy had multiple hospitalizations
Received 9 July 2014
during the past 2 years either due to congestive heart failure, stroke, scar epilepsy, or atrial
Accepted 4 June 2015
fibrillation and ventricular tachycardia. Medication included evidence based therapy for
Available online 8 August 2015
heart failure, cordarone and warfarin. Anticoagulation had to be discontinued due to marked fluctuations in INR. Transthoracic Echocardiography (TTE) revealed a mobile mass in the left
Keywords:
ventricle. He was treated with Dabigatran 110 mg twice a day for 4 months without any
Mass
bleeding or embolic episode and complete resolution of thrombus.
Left ventricle
Dabigatran is a reversible direct thrombin inhibitor and currently approved for the preven-
Dabigatran
tion of thromboembolic episodes in non-valvar atrial fibrillation. This case demonstrates
Thrombolytic
possible thrombolytic properties of dabigatran in resolution of left ventricular thrombus. # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
A 61-year-old male patient in dilated phase of hypertrophic cardiomyopathy had multiple hospitalizations during the past 2 years either due to congestive heart failure, stroke, scar epilepsy, or atrial fibrillation and ventricular tachycardia. He also had diabetes mellitus and hypertension. The 'CHADS2' score was 5. His creatinine clearance was 71.31 ml/min. Medication included ramipril, carvedilol, furosemide, aldactone, cordarone, warfarin, phenytoin sodium, and insulin. Anticoagulation had to be discontinued due to marked fluctuations in International Normalized Ratio (INR). Cordarone and phenytoin would have contributed to the INR variations. During recent hospitalization for aggravation of heart failure, chest X-ray demonstrated cardiomegaly and pulmonary congestion. Transthoracic Echocardiography (TTE)
revealed a mobile mass measuring 2.30 1.16 cm2 in the left ventricle (Panel A, video 1). He was treated with Dabigatran 110 mg twice a day for the past 4 months without any bleeding or embolic episode and resulted in complete resolution of thrombus (Panel B, video 2) (Fig. 1). Dabigatran is a reversible direct thrombin inhibitor and is currently approved for the prevention of thromboembolic episodes in non-valvar atrial fibrillation1 and in those undergoing orthopedic surgery.2 The effects of novel oral anticoagulants on intracardiac thrombi have not been elucidated. There are scattered reports of their use in left atrial thrombus with variable response ranging from increase in its size to resolution of clot.3,4 Its potential to inhibit thrombin bound to fibrin and fibrin degradation products might be
* Corresponding author at: C/O Dr. Satyavan Sharma, Room no. 104, 1st Floor, New Wing, Bombay Hospital, New Marine Lines, Mumbai, Maharashtra 400020, India. Tel.: +91 22 22054532; fax: +91 22 22064533. E-mail address: [email protected] (S. Kolekar). http://dx.doi.org/10.1016/j.ihj.2015.06.010 0019-4832/# 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
496
[(Fig._1)TD$IG]
indian heart journal 67 (2015) 495–496
Fig. 1 – Transthoracic Echocardiography images; Panel A: mobile thrombus 2.3 1.16 cm2 in left ventricle; Panel B: complete resolution of thrombus after treatment with Dabigatran.
responsible for thrombolysis in this patient. As an alternate hypothesis, possibility of spontaneous clot lysis cannot be excluded. The short (4 months) follow-up in this case demonstrates possible thrombolytic properties of Dabigatran in resolution of left ventricular thrombus. This observation needs to be confirmed by larger and long-term data.
Conflicts of interest The authors have none to declare.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ihj.2015.06.010.
references
1. Camm AJ, Lip GY, De Caterina R, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the ESC Guidelines for the 2010 management of atrial fibrillation [34_TD$IF]developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;[35_TD$IF] 33:2719–2747. 2. Garza R, Huo MH. Thromboembolic prophylaxis in orthopedic surgery using dabigatran: an oral direct thrombin inhibitor. Expert Rev Cardiovasc Ther. 2012;[36_TD$IF]10:423–427. 3. Luis SA, Poon K, Luis C, et al. Massive left atrial thrombus in a patient with rheumatic mitral stenosis and atrial fibrillation while anticoagulated with dabigatran. Circ Cardiovasc Imaging. 2013;[37_TD$IF]6:491–492. 4. Morita S, Ajiro Y, Uchida Y, Iwade K. Dabigatran for left atrial thrombus. Eur Heart J. 2013;[35_TD$IF][834:2745.