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      Optimal nonvitamin K antagonist oral anticoagulant therapy in a warfarin-sensitive patient after left atrial appendage closure : A case report

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          Abstract

          Rationale:

          Developing an optimal medication strategy poses a challenging task in fragile patients after left atrial appendage closure (LAAC). We report an optimal nonvitamin K antagonist oral anticoagulant (NOAC) therapy in a warfarin-sensitive patient after LAAC.

          Patient concerns:

          A 77-year-old nonvalvular atrial fibrillation (NVAF) male carrying 2 warfarin-sensitive alleles experienced 2 gum-bleeding with the international normalized ratio (INR) around 3.

          Diagnoses:

          Persistent NVAF with a history of subtotal gastrectomy and moderate renal insufficiency.

          Interventions:

          Warfarin was discontinued and vitamin K1 was immediately administrated via intravenous infusion. LAAC was regarded as a preferable option, and rivaroxaban 15 mg daily was managed after LACC.

          Outcomes:

          Complete endothelialization on the surface of device was detected via transoesophageal echocardiography (TEE), and no peridevice spillage and adverse event occurred.

          Lessons:

          A post-LAAC treatment with NOAC may be a viable regimen in patients intolerant to warfarin.

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          Most cited references10

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          Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry.

          Petr Neuzil, Saibal Kar, Swarnalatha Y Reddy … (2011)
          The Watchman Left Atrial Appendage System for Embolic Protection in Patients With AF (PROTECT AF) randomized trial compared left atrial appendage closure against warfarin in atrial fibrillation (AF) patients with CHADS₂ ≥1. Although the study met the primary efficacy end point of being noninferior to warfarin therapy for the prevention of stroke/systemic embolism/cardiovascular death, there was a significantly higher risk of complications, predominantly pericardial effusion and procedural stroke related to air embolism. Here, we report the influence of experience on the safety of percutaneous left atrial appendage closure. The study cohort for this analysis included patients in the PROTECT AF trial who underwent attempted device left atrial appendage closure (n=542 patients) and those from a subsequent nonrandomized registry of patients undergoing Watchman implantation (Continued Access Protocol [CAP] Registry; n=460 patients). The safety end point included bleeding- and procedure-related events (pericardial effusion, stroke, device embolization). There was a significant decline in the rate of procedure- or device-related safety events within 7 days of the procedure across the 2 studies, with 7.7% and 3.7% of patients, respectively, experiencing events (P=0.007), and between the first and second halves of PROTECT AF and CAP, with 10.0%, 5.5%, and 3.7% of patients, respectively, experiencing events (P=0.006). The rate of serious pericardial effusion within 7 days of implantation, which had made up >50% of the safety events in PROTECT AF, was lower in the CAP Registry (5.0% versus 2.2%, respectively; P=0.019). There was a similar experience-related improvement in procedure-related stroke (0.9% versus 0%, respectively; P=0.039). Finally, the functional impact of these safety events, as defined by significant disability or death, was statistically superior in the Watchman group compared with the warfarin group in PROTECT AF. This remained true whether significance was defined as a change in the modified Rankin score of ≥1, ≥2, or ≥3 (1.8 versus 4.3 events per 100 patient-years; relative risk, 0.43; 95% confidence interval, 0.24 to 0.82; 1.5 versus 3.7 events per 100 patient-years; relative risk, 0.41; 95% confidence interval, 0.22 to 0.82; and 1.4 versus 3.3 events per 100 patient-years; relative risk, 0.43; 95% confidence interval, 0.22 to 0.88, respectively). As with all interventional procedures, there is a significant improvement in the safety of Watchman left atrial appendage closure with increased operator experience. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00129545.
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            The left atrial appendage: anatomy, function, and noninvasive evaluation.

            Roy Beigel, Nina Wunderlich, Siew Yen Ho … (2014)
            The left atrial appendage (LAA) is a finger-like extension originating from the main body of the left atrium. Atrial fibrillation (AF) is the most common clinically important cardiac arrhythmia, occurring in approximately 0.4% to 1% of the general population and increasing with age to >8% in those >80 years of age. In the presence of AF thrombus, formation often occurs within the LAA because of reduced contractility and stasis; thus, attention should be given to the LAA when evaluating and assessing patients with AF to determine the risk for cardioembolic complications. It is clinically important to understand LAA anatomy and function. It is also critical to choose the optimal imaging techniques to identify or exclude LAA thrombi in the setting of AF, before cardioversion, and with current and emerging transcatheter therapies, which include mitral balloon valvuloplasty, pulmonary vein isolation, MitraClip (Abbott Laboratories, Abbott Park, Illinois) valve repair, and the implantation of LAA occlusion and exclusion devices. In this review, we present the current data regarding LAA anatomy, LAA function, and LAA imaging using the currently available noninvasive imaging modalities.
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              Rivaroxaban vs. warfarin in Japanese patients with atrial fibrillation – the J-ROCKET AF study –.

              Masatsugu Hori, Masayasu Matsumoto, Norio Tanahashi … (2012)
              The global ROCKET AF study evaluated once-daily rivaroxaban vs. warfarin for stroke and systemic embolism prevention in patients with atrial fibrillation (AF). A separate trial, J-ROCKET AF, compared the safety of a Japan-specific rivaroxaban dose with warfarin administered according to Japanese guidelines in Japanese patients with AF. J-ROCKET AF was a prospective, randomized, double-blind, phase III trial. Patients (n=1,280) with non-valvular AF at increased risk for stroke were randomized to receive 15 mg once-daily rivaroxaban or warfarin dose-adjusted according to Japanese guidelines. The primary objective was to determine non-inferiority of rivaroxaban against warfarin for the principal safety outcome of major and non-major clinically relevant bleeding, in the on-treatment safety population. The primary efficacy endpoint was the composite of stroke and systemic embolism. Non-inferiority of rivaroxaban to warfarin was confirmed; the rate of the principal safety outcome was 18.04% per year in rivaroxaban-treated patients and 16.42% per year in warfarin-treated patients (hazard ratio [HR] 1.11; 95% confidence interval 0.87-1.42; P<0.001 [non-inferiority]). Intracranial hemorrhage rates were 0.8% with rivaroxaban and 1.6% with warfarin. There was a strong trend for a reduction in the rate of stroke/systemic embolism with rivaroxaban vs. warfarin (HR, 0.49; P=0.050). J-ROCKET AF demonstrated the safety of a Japan-specific rivaroxaban dose and supports bridging the global ROCKET AF results into Japanese clinical practice.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Medicine (Baltimore)
                Journal ID (iso-abbrev): Medicine (Baltimore)
                Journal ID (publisher-id): MEDI
                Title: Medicine
                Publisher: Wolters Kluwer Health
                ISSN (Print): 0025-7974
                ISSN (Electronic): 1536-5964
                Publication date Collection: May 2018
                Publication date (Electronic): 04 May 2018
                Volume: 97
                Issue: 18
                Electronic Location Identifier: e0683
                Affiliations
                [a ]Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University
                [b ]Department of Pharmacy, Third Affiliated Hospital of Second Military Medical University
                [c ]Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
                Author notes
                [∗ ]Correspondence: Zhi-Chun Gu, Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Pujian Road 160, Shanghai 200127, China (e-mail: guzhichun213@ 123456163.com ).
                Article
                Publisher ID: MD-D-18-00806 Accession ID: 00683
                DOI: 10.1097/MD.0000000000010683
                PMC ID: 6392999
                PubMed ID: 29718897
                SO-VID: a0ada1a9-5150-40ea-a3f7-b533fcf2fe92
                Copyright © Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

                History
                Date received : 30 January 2018
                Date accepted : 17 April 2018
                Categories
                Subject: 3400
                Subject: Research Article
                Subject: Clinical Case Report
                Custom metadata
                OPEN-ACCESS TRUE

                Keywords: anticoagulant,atrial fibrillation,left atrial appendage closure,nonvitamin k antagonists,rivaroxaban
                Data availability:
                Keywords: anticoagulant, atrial fibrillation, left atrial appendage closure, nonvitamin k antagonists, rivaroxaban

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