Non-Vitamin K Oral Anticoagulants for the Treatment of a Left Ventricular Thrombus: Review of Literature and Case Series

Abstract

Left ventricular thrombus (LVT) formation is a well-recognized complication of both ischemic and non-ischemic cardiomyopathies with high incidence of embolic stroke 2-3% in untreated patients. The current therapeutic strategy for LVT is warfarin therapy. However, warfarin therapy has several limitations including a narrow therapeutic window, food and drug interactions, and the need for frequent laboratory monitoring. Non-vitamin K oral anticoagulants (NOACs) have several advantages over vitamin K antagonists (VKA) but their efficacy and safety in this context is unknown. We reviewed the literature and published case reports and series for efficacy, safety, and risks of using NOACs as a treatment option for adults with LVT. PubMed, Embase, Medline, Scopus, Web of Science, and Cochrane Library were searched for published articles and case reports. We included guidelines, and treatment reviews of NOACs use among patients with a diagnosis of LVT. The data was set until first of June 2019 with total of 53 cases. Published cases showed majority of cases used Rivaroxaban (60%), Dabigatran (18.8%), Apixaban (18.8%) and one case used Edoxaban. In six cases NOACs failed to dissolve the LVT, dabigatran was used in two cases and rivaroxaban was used in four cases. Two cases under rivaroxaban treatment developed GI bleeding and pulmonary hemorrhage. LVT was successfully resolved in (87.5%) of rivaroxaban cases, (80%) of Dabigatran cases and (100%) for Apixaban cases. The average duration for thrombus resolution was 3 months, 11 weeks, 4 months and 23 days for Rivaroxaban, Dabigatran, Apixaban and Edoxaban respectively. There is limited evidence about the efficacy of NOACs in LVT treatment, currently. published case reports and series showed successful resolution of LVT with NOACs but still NOACs are recommended for patients who are intolerable to VKA. Further randomized controlled trials are needed to confirm the encouraging observational data and determine optimal dosage of NOACs.