Resolution of left ventricular thrombus by edoxaban after failed treatment with warfarin overdose: A case report

Abstract

Rationale: Although novel oral-anticoagulants are widely used in patients with atrial fibrillation (AF) for stroke prevention, there was only limited evidence for their use in left ventricular (LV) thrombus.

Patient concerns: A 41-year-old man who presented with acute onset of right-hand clumsiness and aphasia even under high international normalized ratio (INR: 7.64) from warfarin use. He was previously treated with warfarin for the LV thrombus and non-valvular AF. Brain magnetic resonance imaging (MRI) showed multiple acute infarction in the cortex of the bilateral frontal lobes, left parietal lobe, and bilateral central semiovale, which highly suggested embolic stroke.

Diagnosis: The repeated transthoracic echocardiogram still revealed LV thrombus (1.27 × 0.90 cm), which failed to respond to warfarin therapy.

Interventions: Due to acute infarctions occurred under supratherapeutic range of INR, we switched warfarin to edoxaban (dose: 60 mg/day) after INR decreased to less than 2.

Outcomes: The thrombus disappeared after receiving edoxaban for 23 days, and no more recurrent stroke was noted for more than 6 months.

Lessons: This is the first case demonstrates that while facing ineffective treatment of warfarin for LV thrombus, edoxaban could be safely and effectively used under this situation.

Figure 1

Transthoracic echocardiography before treatment of warfarin revealed left ventricular thrombus in size of 1.75 × 1.68 cm (A). Shrinkage of left ventricular thrombus after treatment of warfarin for 3 weeks (B).

Figure 2

(A) T2 FLAIR images and (B) DWI of the brain MRI. The brain MRI showed multiple hyperintense lesions on DWI and FLAIR in the cortex of the bilateral frontal lobes and left parietal lobe, which highly suggested acute embolic infarction. DWI = Diffusion-weighted imaging, FLAIR = Fluid-attenuated inversion recovery, MRI = Magnetic Resonance Imaging.