alexa Resolution of Left Ventricular Thrombus after Dabigatran Therapy in Two Patients with Old Anteroseptal Myocardial Infarction | Open Access Journals
ISSN: 2329-6607
Cardiovascular Pharmacology: Open Access
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Resolution of Left Ventricular Thrombus after Dabigatran Therapy in Two Patients with Old Anteroseptal Myocardial Infarction

Tadashi Yamamoto*, Takao Konishi, Naohiro Funayama, Beni Kikuchi, Daisuke Hotta and Katsumi Ohori

Department of Cardiovascular Medicine, Hokkaido Cardiovascular Hospital, Sapporo, Japan

*Corresponding Author:
Tadashi Yamamoto
Department of Cardiovascular Medicine
Hokkaido Cardiovascular Hospital
1-30 South 27 West 13, Chuoku
Sapporo, 064-8622, Japan
Tel: +81-11-563-3911
Fax: +81-11-551-3109
E-mail: [email protected] pa2.so-net.ne.jp

Received date: July 29, 2015; Accepted date: August 17, 2015; Published date: August 26, 2015

Citation: Yamamoto T, Konishi T, Funayama N, Kikuchi B, Hotta D, et al. (2015) Resolution of Left Ventricular Thrombus after Dabigatran Therapy in Two Patients with Old Anteroseptal Myocardial Infarction. Cardiol Pharmacol 4:152. doi: 10.4172/2329-6607.1000152

Copyright: © 2015 Yamamoto T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Cardiovascular Pharmacology: Open Access

Abstract

Dabigatran has been used recently as an alternative to warfarin therapy for the prevention of thromboembolism in patients with myocardial infarction or atrial fibrillation, but treatment of established intracardiac thrombus with dabigatran has seldom been reported. We report two patients with left ventricular (LV) thrombus who were successfully treated with dabigatran. The first patient was a 52-year-old man with no clear symptoms who was referred for investigation of abnormal electrocardiography findings, and the second patient was a 51-year-old man with recent onset of heart failure and a history of chest pain 1 month previously. Both patients were diagnosed with old anteroseptal myocardial infarction after echocardiography showed abnormal LV wall motion and LV thrombus. The thrombus was thought to be chronic in the first patient, and to have formed within the preceding month in the second patient. After treatment with dabigatran 220 mg/day and antiplatelet drugs, repeat echocardiography showed resolution of the thrombus after 6 weeks and 2 weeks, respectively. These cases illustrate that dabigatran 220 mg/ day may be useful for the treatment of established LV thrombus.

Keywords

Dabigatran; Myocardial infarction; Left ventricular thrombus; Thrombolysis

Introduction

Anteroseptal myocardial infarction (MI) is associated with formation of left ventricular (LV) thrombus, [1-3] which may result in embolic complications [4,5]. LV thrombus can resolve after warfarin therapy, [6] and has recently been shown to resolve after dabigatran therapy [7]. Dabigatran has also been used as an alternative to warfarin for prophylaxis against thromboembolism in patients with atrial fibrillation [8]. Dabigatran is thought to have a stronger thrombolytic effect compared with other drugs that enhance susceptibility to fibrinolysis [7,9]. Here, we describe two patients with old anteroseptal MI and LV thrombus, who were treated with dabigatran resulting in resolution of thrombus.

Case Reports

Case 1

A 52-year-old man was referred to our department because electrocardiography showed abnormal Q waves in V1–V4. He did not present with a clear history of chest pain. Echocardiography showed apical hypokinesis and LV thrombus measuring 7 × 9 mm (Figure 1a). He was diagnosed with old anteroseptal MI because there was no elevation in cardiac enzyme levels, no history of chest pain, and no ST elevation on electrocardiography. Cardiac computed tomography confirmed LV thrombus (Figure 1b), and showed severe stenosis of the proximal left anterior descending artery (LAD). His creatinine level was 0.81 mg/dL and his estimated glomerular filtration rate was 79.0 ml/min/1.73 m2. He was treated as an outpatient with dabigatran 220 mg/day (Prazaxa®: Nippon Boehringer-Ingelheim, Tokyo, Japan), aspirin 100 mg/day, and clopidogrel 75 mg/day, and was scheduled for percutaneous coronary intervention. Repeat echocardiography after 6 weeks showed resolution of LV thrombus (Figure 1c). The longest activated partial thromboplastin time was 43.6 s. Percutaneous coronary intervention resulted in successful revascularization of the LAD and improvement of LV wall motion, and dabigatran therapy was discontinued.

cardiovascular-pharmacology-Case-1-Imaging-findings

Figure 1: Case 1 Imaging findings.

Case 2

A 51-year-old man was referred to our department because of heart failure. Electrocardiography showed abnormal Q waves in V2– V4. Echocardiography showed anteroseptal akinesis and LV thrombus measuring 24 × 19 mm (Figure 2a). The patient reported chest pain approximately 1 month previously. He was diagnosed with old anteroseptal MI. Cardiac computed tomography showed LV thrombus and complete occlusion of the mid LAD (Figure 2b). His creatinine level was 1.31 mg/dL and his estimated glomerular filtration rate was 46.7 ml/min/1.73 m2. He was treated for heart failure with infusion of heparin (15,000 U/day) and human atrial natriuretic peptide (0.025 μg/ kg/min). Three days after admission, heparin infusion was discontinued and he was started on dabigatran 220 mg/day and aspirin 100 mg/day. Repeat echocardiography and cardiac computed tomography after 2 weeks showed resolution of the LV thrombus (Figure 2c,d). The longest activated partial thromboplastin time was 36.8 s. Dabigatran 220 mg/ day was continued because LV wall motion did not improve. There was no further evidence of thromboembolism during follow-up.

cardiovascular-pharmacology-Case-2-Imaging-findings

Figure 2: Case 2 Imaging findings.

Discussion

Here, we report two patients who developed LV thrombus after anteroseptal MI, who were treated with dabigatran 220 mg/day resulting in resolution of thrombus. In the first case, it was unknown when the LV thrombus formed, and resolution of the thrombus was confirmed 6 weeks after the start of dabigatran therapy. In the second case, LV thrombus was thought to have formed during the preceding month. This thrombus reduced in size to 15 × 12 mm after 1 week of dabigatran therapy, and complete resolution was confirmed after 2 weeks of dabigatran therapy. It is difficult to determine whether LV thrombus is acute or chronic. It was previously reported that chronic LV thrombus after MI did not resolve after vitamin K antagonist therapy [10]. In our patients, the thrombolytic action of dabigatran resulted in resolution of LV thrombus, even though the thrombus may have been chronic in one case, and the thrombus did not recur during dabigatran therapy. However, it is also possible that dabigatran and treatment to inhibit thrombus formation (such as heparin in case 2) may have simultaneously contributed to dissolution. LV thrombus is reported to occur in up to 60% of patients with anteroseptal MI [1].

The reduction in LV wall motion after anteroseptal MI results in thrombus formation at the apex, and there is a causal relationship between LV aneurysm and LV thrombus formation [11]. Thrombus can be treated with warfarin, [12,13] but dabigatran can be considered an alternative to warfarin therapy. Five previous cases of dabigatran administration resulting in resolution of thrombus have been reported [7,14-17]. The reported doses of dabigatran ranged from 220 to 300 mg/day, and resolution was confirmed after 3 weeks or longer (Table 1). Dabigatran is thought to be suitable for the treatment of thrombus because it enhances susceptibility to fibrinolysis in a similar manner to warfarin [18]. In our two cases, dabigatran had a thrombolytic effect at a dose of 220 mg/day. Dabigatran is associated with a lower risk of hemorrhage compared with warfarin, which is useful when given in combination with antiplatelet therapy in patients with ischemic heart disease [19].

Report (yr.) Patient
Age (yr.) / Sex
Thrombus site Underlying
disease
Diagnostic tests Dabigatran dose Thrombus disappearance
period
Vidal A et al. [16] (2012) 59 / F Left atrial appendage AF TTE 300 mg/day 4 weeks
Nagamoto Y et al. [10] (2013) 77 / M Left ventricular apex OMI anterior UCG, CT 220 mg/day 27 days
Morita S et al. [17] (2013) 72 / F Left atrial appendage AF TTE 300 mg/day 4 months
Takeuchi H [18] (2013) 73 / M Pulmonary vein AF 64-MDCT 300 mg/day 3 months
Kaku B [19] (2013) 59 / M Left atrial appendage AF UCG 300 mg/day 3 weeks

Figure 4: Completed facial reconstruction (half-profile, plasticine).

The two cases presented here illustrate that LV thrombus formation after anteroseptal MI can be resolved by treatment with dabigatran 220 mg/day for a few weeks.

Conflict of Interest

None declared.

References

  1. Shacham Y, Leshem Rubinow E, Ben Assa E, Rogowski O, Topilsky Y, et al. (2013) Frequency and correlates of early left ventricular thrombus formation following anterior wall acute myocardial infarction treated with primary percutaneous coronary intervention. Am J Cardiol 111: 667-670.
  2. Delewi R, Nijveldt R, Hirsch A, Marcu CB, Robbers L, et al. (2012) Left ventricular thrombus formation after acute myocardial infarction as assessed by cardiovascular magnetic resonance imaging. Eur J Radiol 81: 3900-3904.
  3. Wada H, Yasu T, Sakakura K, Hayakawa Y, Ishida T, et al. (2014) Contrast echocardiography for the diagnosis of left ventricular thrombus in anterior myocardial infarction. Heart Vessels 29: 308-312.
  4. Sivri N, Yetkin E, Tekin GO, Yalta K, Waltenberger J (2014) Anticoagulation in patients with left ventricular systolic dysfunction and sinus rhythm: When? Clin Appl Thromb Hemost 20: 729-734.
  5. Witt BJ, Ballman KV, Brown RD Jr, Meverden RA, Jacobsen SJ, et al. (2006) The incidence of stroke after myocardial infarction: A meta-analysis. Am J Med 119: 354.
  6. Hurlen M, Abdelnoor M, Smith P, Erikssen J, Arnesen H (2002) Warfarin, aspirin, or both after myocardial infarction. N Engl J Med 347: 969-974.
  7. Nagamoto Y, Shiomi T, Matsuura T, Okahara A, Takegami K, et al. (2014) Resolution of a left ventricular thrombus by the thrombolytic action of dabigatran. Heart Vessels 29: 560-562.
  8. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, et al. (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361: 1139-1151.
  9. Van Ryn JK-EM, Kuritsch I, Wienen W (2009) Effects of direct thrombin or factor Xa inhibition on clot thrombogenicity in vitro: comparison of dabigatran with rivaroxaban and apixaban. J Thromb Haemost 7 (Suppl 2): Abst: PP-WE-181
  10. Niemann M, Gaudron PD, Bijnens B, Störk S, Beer M, et al. (2012) Differentiation between fresh and old left ventricular thrombi by deformation imaging. Circ Cardiovasc Imaging 5: 667-675.
  11. Chan BT, Lim E, Chee KH, Abu Osman NA (2013) Review on CFD simulation in heart with dilated cardiomyopathy and myocardial infarction. Comput Biol Med 43: 377-385.
  12. Siebelink HM, Scholte AJ, Van de Veire NR, Holman ER, Nucifora G, et al. (2009) Value of contrast echocardiography for left ventricular thrombus detection postinfarction and impact on antithrombotic therapy. Coron Artery Dis 20: 462-466.
  13. Choi SH, Jeong SI, Yang JH, Kang IS, Jun TG, et al. (2010) A single-center experience with intracardiac thrombosis in children with dilated cardiomyopathy. Pediatr Cardiol 31: 264-269.
  14. Vidal A, Vanerio G (2012) Dabigatran and left atrial appendage thrombus. J Thromb Thrombolysis 34: 545-547.
  15. Morita S, Ajiro Y, Uchida Y, Iwade K (2013) Dabigatran for left atrial thrombus. Eur Heart J 34: 2745.
  16. Takeuchi H (2013) Floating thrombus in the left upper pulmonary vein dissolved by dabigatran. BMJ Case Rep 2013.
  17. Kaku B (2013) Intra-cardiac thrombus resolution after anti-coagulation therapy with dabigatran in a patient with mid-ventricular obstructive hypertrophic cardiomyopathy: A case report. J Med Case Rep 7: 238.
  18. Yasaka M, Yamaguchi T, Miyashita T, Tsuchiya T (1990) Regression of intracardiac thrombus after embolic stroke. Stroke 21: 1540-1544.
  19. Hori M, Connolly SJ, Zhu J, Liu LS, Lau CP, et al. (2013) Dabigatran versus warfarin: effects on ischemic and hemorrhagic strokes and bleeding in Asians and non-Asians with atrial fibrillation. Stroke 44: 1891-1896.
Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Article Usage

  • Total views: 12128
  • [From(publication date):
    August-2015 - Nov 20, 2017]
  • Breakdown by view type
  • HTML page views : 8283
  • PDF downloads : 3845
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords