Left ventricular mural thrombus despite treatment with dabigatran and clopidogrel

Area of Science:

• Cardiology
• Pharmacology
• Internal Medicine

Background:

• Severe heart failure and moderate aortic stenosis present complex management challenges.
• Patients with atrial fibrillation and ischemic heart disease often require dual antiplatelet and anticoagulant therapy.
• Left ventricular thrombus formation is a serious complication associated with heart failure and reduced ejection fraction.

Observation:

• A large mural thrombus was detected via echocardiography in a patient on dabigatran and clopidogrel.
• Despite switching to warfarin, the left ventricular thrombus showed no resolution over eight months.
• This case illustrates potential resistance to both novel oral anticoagulants and warfarin in left ventricular thrombus management.

Findings:

• The patient exhibited resistance to dabigatran, a direct thrombin inhibitor.
• Warfarin therapy also failed to achieve thrombus resolution, suggesting a complex thrombotic process.
• This case highlights a rare instance of dual anticoagulant resistance in managing left ventricular thrombus.

Implications:

• There is a critical need for updated clinical guidelines regarding anticoagulant use for left ventricular thrombi.
• Further research is warranted to understand mechanisms of anticoagulant resistance in left ventricular thrombus.
• Novel therapeutic approaches may be required for patients with refractory left ventricular thrombi.