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Percutaneous Occlusion of the Left Atrial Appendage with the Watchman Device in an Active Duty Sailor with Atrial Fibrillation and Recurrent Thromboembolism Despite Appropriate Use of Oral Anticoagulation

Percutaneous Occlusion of the Left Atrial Appendage with the Watchman Device in an Active Duty... Downloaded from https://academic.oup.com/milmed/article/183/11-12/e771/5001567 by DeepDyve user on 19 July 2022 MILITARY MEDICINE, 183, 11/12:e771, 2018 Percutaneous Occlusion of the Left Atrial Appendage with the Watchman Device in an Active Duty Sailor with Atrial Fibrillation and Recurrent Thromboembolism Despite Appropriate Use of Oral Anticoagulation CDR Justin M. Cox, MC, USN*; CDR Anthony J. Choi, MC, USN*; LCDR Luke S. Oakley, MC, USN†; Gregory M. Francisco, MD*; CAPT Keshav R. Nayak, MC, USN* ABSTRACT Atrial fibrillation is the most common significant cardiac arrhythmia and is associated with a five-fold increased risk of stroke from thromboembolism. Over 94% of these emboli arise from the left atrial appendage. Systemic embolic phenomena are rare, accounting for less than 1 out of 10 of all embolic events, but have a similar prevention strategy. Anticoagulation significantly reduces the risk of these events, and thus forms the cornerstone of therapy for most patients with atrial fibrillation. Left atrial appendage occlusion with the Watchman device is a recently approved alternative for stroke prevention in selected patients. We present a case of an active duty U.S. Navy sailor at low risk for thromboembolism who nonetheless suffered recurrent thromboembolic events despite appropriate anticoa- gulation, and thus underwent Watchman implantation. The therapy in this case will ideally provide a lifetime of protec- tion from recurrent systemic embolization while allowing the patient to continue his active duty military career without restriction due to oral anticoagulation. INTRODUCTION CASE PRESENTATION Atrial fibrillation (AF) is the most common cardiac arrhythmia, A 39-yr-old active duty male U.S. Navy sailor presented to affecting up to six million Americans. The presence of AF the Emergency Department with less than 24 h of palpita- confers significant morbidity and mortality, including a five- tions. He recalled two prior episodes which each lasted less fold increased risk of stroke or transient ischemic attack. In than 2 h. ECG demonstrated AF (Fig. 1). Transthoracic patients with AF, it is estimated that over 94% of cardiogenic echocardiogram demonstrated mild concentric left ventricu- emboli arise from thrombi formed in the left atrial appendage lar hypertrophy, normal bi-ventricular systolic function, and (LAA). Anticoagulation prevents thrombus formation and normal valve function. His CHA DS -VASc score was zero, 2 2 thus reduces the risk of embolization by approximately 64%, so he underwent pharmacologic cardioversion with flecai- so is recommended for patients with an elevated stroke risk. nide and was discharged home. Ten days later he represented In 2015, the U.S. Food and Drug Administration (FDA) with a painful left index finger. Examination demonstrated approved the Watchman Left Atrial Appendage Closure diminished left radial and ulnar pulses and a cold hand. Device (Boston Scientific, Natick, Massachusetts) as an alter- Urgent angiography revealed emboli in the left radial, ulnar, native to long-term anticoagulation in select patients with a and interosseous arteries (Fig. 2). Treatment with intra- high risk of stroke. Here we present a 39-yr-old active duty U. arterial tPA and heparin restored antegrade and his symp- S. Navy sailor with non-valvular AF who suffered recurrent toms resolved over the next 24 h. Brain MRI demonstrated thromboembolic events despite appropriate use of oral anticoa- no evidence of cerebral emboli, and he was started on rivar- gulation, who was ultimately treated with the Watchman oxaban, flecainide, and metoprolol for long-term treatment device. This is an uncommon scenario with no clinical trial and secondary prevention. data to guide decision-making, but this approach presents Three years later, he awoke with severe flank pain, and unique advantages, especially for active duty service members. again presented to the Emergency Department. Initial evalu- ation demonstrated new hypertension and an abdominal CT showed complete occlusion of the right renal artery (Fig. 3). *Department of Cardiology, Bldg-3 Suite-303, Naval Medical Center San Diego, San Diego, CA 92134. Transesophageal echocardiogram demonstrated no cardiac †Department of Cardiology, Eagle Pavilion 2nd Floor, Fort Belvoir thrombi and an intact atrial septum. Adherence with anticoagu- Community Hospital, Fort Belvoir, VA 22314. lation was verified, and an extensive evaluation for a hypercoag- The views expressed are solely those of the authors and do not reflect ulable disorder was unremarkable. A multidisciplinary heart the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, team (consisting of several general cardiologists, interventional- the Department of Defense, or the U.S. Government. doi: 10.1093/milmed/usy099 ists, and electrophysiologists) concluded that this recurrent Published by Oxford University Press on behalf of Association of thromboembolism represented a failure of anticoagulation and Military Surgeons of the United States 2018. This work is written by (a) US recommended percutaneous LAA occlusion with the Watchman Government employee(s) and is in the public domain in the US. MILITARY MEDICINE, Vol. 183, November/December 2018 e771 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e771/5001567 by DeepDyve user on 19 July 2022 Case Report FIGURE 1. ECG from the patient’s initial presentation, demonstrating rate controlled AF with left ventricular hypertrophy and repolarization abnormality. FIGURE 2. Left arm angiogram demonstrating occlusion of the radial, ulnar, and interosseous arteries by multiple emboli. device (Fig. 4). Continuation of anticoagulation after LAA occlusion was considered as a “belt and suspenders” approach, but was decided against after carefully weighing the long-term risk of anticoagulation. DISCUSSION AF is the most common serious cardiac arrhythmia, affecting up to six million Americans, and is associated with a five-fold increased risk of stroke. Extracranial, or systemic, embolic events are less common. In one review of 37,973 patients from four large anticoagulation trials, systemic emboli accounted for only 10% of thromboembolic events, but were just as fatal as stroke, with a 30-day mortality of 24%. The most widely used method of quantifying the risk of stroke is the CHA DS -VASc 2 2 score (congestive heart failure, hypertension, age ≥75 yr, diabe- tes, prior stroke or transient ischemic attack, vascular disease, FIGURE 3. Contrast CT demonstrating occlusion of the right renal artery (arrow) with resultant hypo-perfusion of the renal cortex. age 65–74 yr, and female sex category). In this scheme, higher e772 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e771/5001567 by DeepDyve user on 19 July 2022 Case Report FIGURE 4. Intra-procedural imaging from the Watchman implantation. (A) Pre-implantation transesophageal imaging of the LAA demonstrating no evi- dence of thrombus; (B) LAA angiography in left anterior-oblique-caudal projection demonstrating a large ‘chicken wing’ shaped appendage; (C) fluoroscopy of the Watchman after deployment at the orifice of the LAA; (D) one of four measurements of deployed device confirming position, compression, and absence of flow. scores indicate a greater stroke risk, and both age ≥75 and prior anticoagulation use and adherence, so this was considered a stroke or transient ischemic attack are given two points. failure of anticoagulation. This patient’s CHA DS -VASc score was zero on initial The optimal management after such breakthrough events 2 2 presentation, so no anticoagulation was prescribed after phar- is unclear. The following strategies have been proposed; macologic cardioversion. This is in accordance with AF dose escalation, switching to an alternative anticoagulant, guidelines, which state that anticoagulation or no antithrombo- adding an antiplatelet agent, and non-pharmacologic treat- tic may be considered for cardioversion in patients with AF or ment via LAA occlusion. Evidence for dose escalation atrial flutter of less than 48-h duration. Moreover, in a retro- comes primarily from the RE-LY trial and the direct throm- spective study of 484 patients with less than 48 h of AF who bin inhibitor oral anticoagulant dabigatran. In contrast, riv- underwent cardioversion, there were no thromboembolic aroxaban efficacy did not correlate with dose in the phase II 5 11,12 events in those with CHA DS -VASc scores less than two. trials that influenced dose selection in AF treatment. 2 2 A similar study found a very low event rate in those without Changing to an alternative anticoagulant has unknown effi- diabetes or heart failure. cacy, as there have been no trials of this method or head-to- Despite low predicted risk, this patient experienced multi- head comparisons between direct oral anticoagulants. The ple systemic embolic events; first occlusion of multiple arter- addition of an antiplatelet agent to anticoagulation has also ies in the left arm off anticoagulation, and later occlusion of been advocated, but may not reduce the risk of thromboem- the right renal artery despite anticoagulation with rivaroxa- bolism and significantly increases the risk of bleeding. ban. Rates of thromboembolism in patients on rivaroxaban LAA occlusion with the Watchman device has recently are very low; in one trial of AF patients with an average emerged as another option for the prevention of thromboem- CHA DS -VASc score of 3.5 there were only 1.7 strokes bolism in selected patients with AF. The implant is composed 2 2 per 100 patient years. When such breakthrough thromboem- of a nitinol frame and a permeable polyester fabric over the bolic events occur, non-adherence should be considered. atrial cap. Small fixation barbs hold it in the LAA, and Rivaroxaban must be taken every day without interruptions, endothelialization gradually covers the device and seals nthe and with the evening meal, as it has 34% lower bioavailabil- appendage. The Watchman device received FDA approval in ity when taken without food. For this patient, interviews 2015 for AF patients at risk for stroke who are suitable for and review of prescription records verified appropriate short term anticoagulation but have an appropriate rationale to MILITARY MEDICINE, Vol. 183, November/December 2018 e773 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e771/5001567 by DeepDyve user on 19 July 2022 Case Report Heart Association Task Force on practice guidelines and the Heart seek a non-pharmacologic alternative to warfarin. Compared Rhythm Society. Circulation 2014; 64(21): 2014–5. with warfarin, the Watchman device is noninferior for the pre- 3. Manning WJ, Silverman DI, Keighley CS, Oettgen P, Douglas PS: vention of stroke in at-risk patients with AF, and is associated Transoesophageal echocardiographically facilitated early cardioversion with a significant reduction in bleeding. Its efficacy in from atrial fibrillation using short-term anticoagulation: results of a pro- patients with failure of direct oral anticoagulants such as rivar- spective 4.5 year study. J Am Coll Cardiol 1995; 25(6): 1354–61. 4. Bekwelem W, Adabag S, Duval S, et al: Extracranial systemic embolic oxaban has not been studied. events in patients with atrial fibrillation: incidence and outcomes. Given this patient’s young age and failure of oral anticoa- Circulation 2013; 128(22 SUPPL. 1): 796–803. gulation with rivaroxaban, the Watchman Device represented 5. Garg A, Khunger M, Seicean S, Chung MK, Tchou PJ: Incidence of attractive option. Although unproven for this indication, it thromboembolic complications within 30 days of electrical cardiover- would prevent the patient from experiencing the cumulative sion performed within 48 hours of atrial fibrillation onset. JACC Clin Electrophysiol 2016; 2(4): 487–94. risk of indefinite anticoagulation. 6. Airaksinen KEJ, Grönberg T, Nuotio I, et al: Thromboembolic compli- One additional consideration for this patient was his prefer- cations after cardioversion of acute atrial fibrillation. J Am Coll Cardiol ence remain on active duty and fully deployable worldwide. 2013; 62(13): 1187–92. Chronic anticoagulation therapy, because of increased bleed- 7. Patel M, Mahaffey K, Garg J: Rivaroxaban versus warfarin in nonvalv- ing, typically is cause for referral to the physical evaluation ular atrial fibrillation. N Engl J Med 2011; 365(10): 883–91. 8. Trujillo T, Dobesh PP: Clinical use of rivaroxaban: pharmacokinetic board. For this patient and other active duty service members and pharmacodynamic rationale for dosing regimens in different indica- with AF, non-pharmacologic prophylaxis of thromboembolism tions. Drugs 2014; 74(14): 1587–603. with the Watchman device thus represents an attractive alterna- 9. Kazmi RS, Lwaleed BA: New anticoagulants: how to deal with treat- tive that may be considered on an individual basis. ment failure and bleeding complications. Br J Clin Pharmacol 2011; 72 (4): 593–603. 10. Connolly SJ, Ezekowitz MD, Yusuf S, et al: Dabigatran versus CONCLUSION Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009; 361 This case demonstrates the rare occurrence of thrombo- (12): 1139–51. 11. Turpie AG, Fisher WD, Bauer KA, et al: BAY 59-7939: an oral, direct embolization in a low risk patient and breakthrough systemic factor Xa inhibitor for the prevention of venous thromboembolism in embolization despite appropriate adherence with rivaroxaban patients after total knee replacement. A phase II dose-ranging study. anticoagulation. It emphasizes how low risk does not equal J Thromb Haemost 2005; 3(11): 2479–86. no risk, and illustrates how LAA occlusion with the Watchman 12. Eriksson BI, Borris LC, Dahl OE, et al: Dose-escalation study of rivar- device may be considered in young patients with oral anticoagu- oxaban (BAY 59-7939) – an oral, direct Factor Xa inhibitor – for the prevention of venous thromboembolism in patients undergoing total hip lation treatment failure. Finally, it introduces some unique con- replacement. Thromb Res 2007; 120(5): 685–93. siderations for active duty military members with AF who wish 13. Lamberts M, Gislason GH, Lip GYH, et al: Antiplatelet therapy for sta- to remain on active duty. ble coronary artery disease in atrial fibrillation patients taking an oral anticoagulant: a nationwide cohort study. Circulation 2014; 129(15): 1577–85. REFERENCES 14. Reddy VY, Sievert H, Halperin J, et al: Percutaneous left atrial append- 1. Mozaffarian D, Benjamin EJ, Go AS, et al: Executive summary: heart dis- age closure vs warfarin for atrial fibrillation a randomized clinical trial. ease and stroke statistics—2016 update. Circulation 2016; 133(4): 447–54. JAMA 2014; 312(19): 1988–98. 2. January CT, Wann LS, Alpert JS, et al: 2014 AHA / ACC / HRS guide- 15. Navas WA. SECNAV INSTRUCTION 1850.4E. Washington, DC, United line for the management of patients with atrial fibrillation: executive States of America; 2002. Available at https://doni.documentservices.dla. summary a report of the American College of Cardiology / American mil/allinstructions.aspx; accessed February 19, 2018. e774 MILITARY MEDICINE, Vol. 183, November/December 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Percutaneous Occlusion of the Left Atrial Appendage with the Watchman Device in an Active Duty Sailor with Atrial Fibrillation and Recurrent Thromboembolism Despite Appropriate Use of Oral Anticoagulation

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Oxford University Press
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Copyright © 2022 The Society of Federal Health Professionals
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0026-4075
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1930-613X
DOI
10.1093/milmed/usy099
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Abstract

Downloaded from https://academic.oup.com/milmed/article/183/11-12/e771/5001567 by DeepDyve user on 19 July 2022 MILITARY MEDICINE, 183, 11/12:e771, 2018 Percutaneous Occlusion of the Left Atrial Appendage with the Watchman Device in an Active Duty Sailor with Atrial Fibrillation and Recurrent Thromboembolism Despite Appropriate Use of Oral Anticoagulation CDR Justin M. Cox, MC, USN*; CDR Anthony J. Choi, MC, USN*; LCDR Luke S. Oakley, MC, USN†; Gregory M. Francisco, MD*; CAPT Keshav R. Nayak, MC, USN* ABSTRACT Atrial fibrillation is the most common significant cardiac arrhythmia and is associated with a five-fold increased risk of stroke from thromboembolism. Over 94% of these emboli arise from the left atrial appendage. Systemic embolic phenomena are rare, accounting for less than 1 out of 10 of all embolic events, but have a similar prevention strategy. Anticoagulation significantly reduces the risk of these events, and thus forms the cornerstone of therapy for most patients with atrial fibrillation. Left atrial appendage occlusion with the Watchman device is a recently approved alternative for stroke prevention in selected patients. We present a case of an active duty U.S. Navy sailor at low risk for thromboembolism who nonetheless suffered recurrent thromboembolic events despite appropriate anticoa- gulation, and thus underwent Watchman implantation. The therapy in this case will ideally provide a lifetime of protec- tion from recurrent systemic embolization while allowing the patient to continue his active duty military career without restriction due to oral anticoagulation. INTRODUCTION CASE PRESENTATION Atrial fibrillation (AF) is the most common cardiac arrhythmia, A 39-yr-old active duty male U.S. Navy sailor presented to affecting up to six million Americans. The presence of AF the Emergency Department with less than 24 h of palpita- confers significant morbidity and mortality, including a five- tions. He recalled two prior episodes which each lasted less fold increased risk of stroke or transient ischemic attack. In than 2 h. ECG demonstrated AF (Fig. 1). Transthoracic patients with AF, it is estimated that over 94% of cardiogenic echocardiogram demonstrated mild concentric left ventricu- emboli arise from thrombi formed in the left atrial appendage lar hypertrophy, normal bi-ventricular systolic function, and (LAA). Anticoagulation prevents thrombus formation and normal valve function. His CHA DS -VASc score was zero, 2 2 thus reduces the risk of embolization by approximately 64%, so he underwent pharmacologic cardioversion with flecai- so is recommended for patients with an elevated stroke risk. nide and was discharged home. Ten days later he represented In 2015, the U.S. Food and Drug Administration (FDA) with a painful left index finger. Examination demonstrated approved the Watchman Left Atrial Appendage Closure diminished left radial and ulnar pulses and a cold hand. Device (Boston Scientific, Natick, Massachusetts) as an alter- Urgent angiography revealed emboli in the left radial, ulnar, native to long-term anticoagulation in select patients with a and interosseous arteries (Fig. 2). Treatment with intra- high risk of stroke. Here we present a 39-yr-old active duty U. arterial tPA and heparin restored antegrade and his symp- S. Navy sailor with non-valvular AF who suffered recurrent toms resolved over the next 24 h. Brain MRI demonstrated thromboembolic events despite appropriate use of oral anticoa- no evidence of cerebral emboli, and he was started on rivar- gulation, who was ultimately treated with the Watchman oxaban, flecainide, and metoprolol for long-term treatment device. This is an uncommon scenario with no clinical trial and secondary prevention. data to guide decision-making, but this approach presents Three years later, he awoke with severe flank pain, and unique advantages, especially for active duty service members. again presented to the Emergency Department. Initial evalu- ation demonstrated new hypertension and an abdominal CT showed complete occlusion of the right renal artery (Fig. 3). *Department of Cardiology, Bldg-3 Suite-303, Naval Medical Center San Diego, San Diego, CA 92134. Transesophageal echocardiogram demonstrated no cardiac †Department of Cardiology, Eagle Pavilion 2nd Floor, Fort Belvoir thrombi and an intact atrial septum. Adherence with anticoagu- Community Hospital, Fort Belvoir, VA 22314. lation was verified, and an extensive evaluation for a hypercoag- The views expressed are solely those of the authors and do not reflect ulable disorder was unremarkable. A multidisciplinary heart the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, team (consisting of several general cardiologists, interventional- the Department of Defense, or the U.S. Government. doi: 10.1093/milmed/usy099 ists, and electrophysiologists) concluded that this recurrent Published by Oxford University Press on behalf of Association of thromboembolism represented a failure of anticoagulation and Military Surgeons of the United States 2018. This work is written by (a) US recommended percutaneous LAA occlusion with the Watchman Government employee(s) and is in the public domain in the US. MILITARY MEDICINE, Vol. 183, November/December 2018 e771 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e771/5001567 by DeepDyve user on 19 July 2022 Case Report FIGURE 1. ECG from the patient’s initial presentation, demonstrating rate controlled AF with left ventricular hypertrophy and repolarization abnormality. FIGURE 2. Left arm angiogram demonstrating occlusion of the radial, ulnar, and interosseous arteries by multiple emboli. device (Fig. 4). Continuation of anticoagulation after LAA occlusion was considered as a “belt and suspenders” approach, but was decided against after carefully weighing the long-term risk of anticoagulation. DISCUSSION AF is the most common serious cardiac arrhythmia, affecting up to six million Americans, and is associated with a five-fold increased risk of stroke. Extracranial, or systemic, embolic events are less common. In one review of 37,973 patients from four large anticoagulation trials, systemic emboli accounted for only 10% of thromboembolic events, but were just as fatal as stroke, with a 30-day mortality of 24%. The most widely used method of quantifying the risk of stroke is the CHA DS -VASc 2 2 score (congestive heart failure, hypertension, age ≥75 yr, diabe- tes, prior stroke or transient ischemic attack, vascular disease, FIGURE 3. Contrast CT demonstrating occlusion of the right renal artery (arrow) with resultant hypo-perfusion of the renal cortex. age 65–74 yr, and female sex category). In this scheme, higher e772 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e771/5001567 by DeepDyve user on 19 July 2022 Case Report FIGURE 4. Intra-procedural imaging from the Watchman implantation. (A) Pre-implantation transesophageal imaging of the LAA demonstrating no evi- dence of thrombus; (B) LAA angiography in left anterior-oblique-caudal projection demonstrating a large ‘chicken wing’ shaped appendage; (C) fluoroscopy of the Watchman after deployment at the orifice of the LAA; (D) one of four measurements of deployed device confirming position, compression, and absence of flow. scores indicate a greater stroke risk, and both age ≥75 and prior anticoagulation use and adherence, so this was considered a stroke or transient ischemic attack are given two points. failure of anticoagulation. This patient’s CHA DS -VASc score was zero on initial The optimal management after such breakthrough events 2 2 presentation, so no anticoagulation was prescribed after phar- is unclear. The following strategies have been proposed; macologic cardioversion. This is in accordance with AF dose escalation, switching to an alternative anticoagulant, guidelines, which state that anticoagulation or no antithrombo- adding an antiplatelet agent, and non-pharmacologic treat- tic may be considered for cardioversion in patients with AF or ment via LAA occlusion. Evidence for dose escalation atrial flutter of less than 48-h duration. Moreover, in a retro- comes primarily from the RE-LY trial and the direct throm- spective study of 484 patients with less than 48 h of AF who bin inhibitor oral anticoagulant dabigatran. In contrast, riv- underwent cardioversion, there were no thromboembolic aroxaban efficacy did not correlate with dose in the phase II 5 11,12 events in those with CHA DS -VASc scores less than two. trials that influenced dose selection in AF treatment. 2 2 A similar study found a very low event rate in those without Changing to an alternative anticoagulant has unknown effi- diabetes or heart failure. cacy, as there have been no trials of this method or head-to- Despite low predicted risk, this patient experienced multi- head comparisons between direct oral anticoagulants. The ple systemic embolic events; first occlusion of multiple arter- addition of an antiplatelet agent to anticoagulation has also ies in the left arm off anticoagulation, and later occlusion of been advocated, but may not reduce the risk of thromboem- the right renal artery despite anticoagulation with rivaroxa- bolism and significantly increases the risk of bleeding. ban. Rates of thromboembolism in patients on rivaroxaban LAA occlusion with the Watchman device has recently are very low; in one trial of AF patients with an average emerged as another option for the prevention of thromboem- CHA DS -VASc score of 3.5 there were only 1.7 strokes bolism in selected patients with AF. The implant is composed 2 2 per 100 patient years. When such breakthrough thromboem- of a nitinol frame and a permeable polyester fabric over the bolic events occur, non-adherence should be considered. atrial cap. Small fixation barbs hold it in the LAA, and Rivaroxaban must be taken every day without interruptions, endothelialization gradually covers the device and seals nthe and with the evening meal, as it has 34% lower bioavailabil- appendage. The Watchman device received FDA approval in ity when taken without food. For this patient, interviews 2015 for AF patients at risk for stroke who are suitable for and review of prescription records verified appropriate short term anticoagulation but have an appropriate rationale to MILITARY MEDICINE, Vol. 183, November/December 2018 e773 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e771/5001567 by DeepDyve user on 19 July 2022 Case Report Heart Association Task Force on practice guidelines and the Heart seek a non-pharmacologic alternative to warfarin. Compared Rhythm Society. Circulation 2014; 64(21): 2014–5. with warfarin, the Watchman device is noninferior for the pre- 3. Manning WJ, Silverman DI, Keighley CS, Oettgen P, Douglas PS: vention of stroke in at-risk patients with AF, and is associated Transoesophageal echocardiographically facilitated early cardioversion with a significant reduction in bleeding. Its efficacy in from atrial fibrillation using short-term anticoagulation: results of a pro- patients with failure of direct oral anticoagulants such as rivar- spective 4.5 year study. J Am Coll Cardiol 1995; 25(6): 1354–61. 4. Bekwelem W, Adabag S, Duval S, et al: Extracranial systemic embolic oxaban has not been studied. events in patients with atrial fibrillation: incidence and outcomes. Given this patient’s young age and failure of oral anticoa- Circulation 2013; 128(22 SUPPL. 1): 796–803. gulation with rivaroxaban, the Watchman Device represented 5. Garg A, Khunger M, Seicean S, Chung MK, Tchou PJ: Incidence of attractive option. Although unproven for this indication, it thromboembolic complications within 30 days of electrical cardiover- would prevent the patient from experiencing the cumulative sion performed within 48 hours of atrial fibrillation onset. JACC Clin Electrophysiol 2016; 2(4): 487–94. risk of indefinite anticoagulation. 6. Airaksinen KEJ, Grönberg T, Nuotio I, et al: Thromboembolic compli- One additional consideration for this patient was his prefer- cations after cardioversion of acute atrial fibrillation. J Am Coll Cardiol ence remain on active duty and fully deployable worldwide. 2013; 62(13): 1187–92. Chronic anticoagulation therapy, because of increased bleed- 7. Patel M, Mahaffey K, Garg J: Rivaroxaban versus warfarin in nonvalv- ing, typically is cause for referral to the physical evaluation ular atrial fibrillation. N Engl J Med 2011; 365(10): 883–91. 8. Trujillo T, Dobesh PP: Clinical use of rivaroxaban: pharmacokinetic board. For this patient and other active duty service members and pharmacodynamic rationale for dosing regimens in different indica- with AF, non-pharmacologic prophylaxis of thromboembolism tions. Drugs 2014; 74(14): 1587–603. with the Watchman device thus represents an attractive alterna- 9. Kazmi RS, Lwaleed BA: New anticoagulants: how to deal with treat- tive that may be considered on an individual basis. ment failure and bleeding complications. Br J Clin Pharmacol 2011; 72 (4): 593–603. 10. Connolly SJ, Ezekowitz MD, Yusuf S, et al: Dabigatran versus CONCLUSION Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009; 361 This case demonstrates the rare occurrence of thrombo- (12): 1139–51. 11. Turpie AG, Fisher WD, Bauer KA, et al: BAY 59-7939: an oral, direct embolization in a low risk patient and breakthrough systemic factor Xa inhibitor for the prevention of venous thromboembolism in embolization despite appropriate adherence with rivaroxaban patients after total knee replacement. A phase II dose-ranging study. anticoagulation. It emphasizes how low risk does not equal J Thromb Haemost 2005; 3(11): 2479–86. no risk, and illustrates how LAA occlusion with the Watchman 12. Eriksson BI, Borris LC, Dahl OE, et al: Dose-escalation study of rivar- device may be considered in young patients with oral anticoagu- oxaban (BAY 59-7939) – an oral, direct Factor Xa inhibitor – for the prevention of venous thromboembolism in patients undergoing total hip lation treatment failure. Finally, it introduces some unique con- replacement. Thromb Res 2007; 120(5): 685–93. siderations for active duty military members with AF who wish 13. Lamberts M, Gislason GH, Lip GYH, et al: Antiplatelet therapy for sta- to remain on active duty. ble coronary artery disease in atrial fibrillation patients taking an oral anticoagulant: a nationwide cohort study. Circulation 2014; 129(15): 1577–85. REFERENCES 14. Reddy VY, Sievert H, Halperin J, et al: Percutaneous left atrial append- 1. Mozaffarian D, Benjamin EJ, Go AS, et al: Executive summary: heart dis- age closure vs warfarin for atrial fibrillation a randomized clinical trial. ease and stroke statistics—2016 update. Circulation 2016; 133(4): 447–54. JAMA 2014; 312(19): 1988–98. 2. January CT, Wann LS, Alpert JS, et al: 2014 AHA / ACC / HRS guide- 15. Navas WA. SECNAV INSTRUCTION 1850.4E. Washington, DC, United line for the management of patients with atrial fibrillation: executive States of America; 2002. Available at https://doni.documentservices.dla. summary a report of the American College of Cardiology / American mil/allinstructions.aspx; accessed February 19, 2018. e774 MILITARY MEDICINE, Vol. 183, November/December 2018

Journal

Military MedicineOxford University Press

Published: Nov 5, 2018

Keywords: anticoagulation; atrial fibrillation; thromboembolism; left auricular appendage; percutaneous left atrial appendage occlusion device; left atrial appendage occlusion; appropriate use; embolism; thromboembolic event

There are no references for this article.