Abstract
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. Medication included evidence based therapy for 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 ventricle. He was treated with Dabigatran 110 mg twice a day for 4 months without any bleeding or embolic episode and complete resolution of thrombus.
Dabigatran is a reversible direct thrombin inhibitor and currently approved for the prevention of thromboembolic episodes in non-valvar atrial fibrillation. This case demonstrates possible thrombolytic properties of dabigatran in resolution of left ventricular thrombus.
Keywords: Mass, Left ventricle, Dabigatran, Thrombolytic
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).
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.
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 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.
Footnotes
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ihj.2015.06.010.
Appendix A. Supplementary data
The following are the supplementary data to this article:
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