PO0005 - Secondary prevention of cardiogenic arterial thromboembolism in a patient with atrial fibrillation and thrombus in left ventricule

Background: Thromboembolism is challenging problem in patients with atrial fibrillation(AF).

Aims: Our aim was prevention of secondary cardiogenic arterial thromboembolism.

Methods: A 77year-old woman presented with paroxysmal-recurrent AF, acute heart failure (HF), bilateral hydrothorax, moderate anemia, chronic kidney disease-IVstage, chronic encephalopathy. 2,5 months ago patient had acute myocardial infarction with bilateral pneumonia and paroxysmal AF (NSTEMI, Killip class III; Coronarography revealed 95% stenosis of ADCA, 95% stenosis of I diagonal branch, 75% stenosis of circumflex CA. 3 stents were implanted in LAD and CCA.). Besides usual treatment she recieved aspirin and rivaroxaban, but last 10 days she quitted medication and became orthopneic. W-68kg, H-165cm, BMI 26,5. Skin pale, cyanosis. Edema on lower extremities, oliguria. P- 98`, irregular. Cor: dull sounds, systolic murmur on apex. TA-160/90mmHg. Pulmo: R-28`, SpO2-88%. Crackles in lower lobes bilaterally. CBC: WBC-6.6×103/µL; RBC-2.43×106/µL; Hb-8.2g/dL; X-ray: Lungs-marked prominence of interstitial lines and hila bilaterally, fluid accumulation in pleural cavity. Cor-enlarged transverse size. Echoscopy revealed 11cm separation in right and 7cm separation in left pleura. Cor: Enlarged left and right atria, left ventricular hypertrophy, scarring on inferio-lateral and apical walls. Not floating thrombus attached at apex(1,6 cm, Fig1). Ejection fraction (EF)-40 %; Moderate pulmonary artery hypertension. Moderate calcinosis and regurgitation of aortic and mitral valves. AF. Patient had serum albumin-28,52g/L, low GFR-26,2ml/min/1,73m2, proteinuria - 30mg/dl and hematuria– 25-28 Er/HPF.

Results: She was treated routinely plus albumin, heparin-i/v, rivaroxaban. 2 thoracentesis was made, 900 ml transudate (according to lab.data) was removed. Patient improved, signs of acute HF disappeared, heart regained sinus rhythm though irregular with frequent atrial premature beats. By echocardiography thrombus was resolved, EF raised up to 44%.

Conclusion(s): Use of rivaroxaban is reasonable not only for treatment of intracardial thrombus, but also to prevent blood clots from forming in patients with congestive HF and AF, especially with previous MI for long-term anticoagulation therapy.