Key result
Heparin and heart failure therapy successfully resolve giant left atrial thrombi without systemic embolism.
Why the study?
Although surgical left atrial appendage resection reduces a major source of thromboembolism, left atrial cavity thrombosis may still occur in patients with persistent severe atrial stasis.
Case Report (n=1)
No
Surgical left atrial appendage resection does not eliminate the risk of giant left atrial cavity thrombosis when severe atrial stasis, rheumatic atrial remodelling, and suboptimal anticoagulation persist, though such thrombi can resolve with unfractionated heparin and heart failure therapy.
Persistent LA stasis may sustain thrombus risk after appendage resection in rheumatic disease; hypothesis-generating for adjunctive strategies beyond resection.
Structured Abstract Background Although surgical left atrial appendage resection reduces a major source of thromboembolism, left atrial cavity thrombosis may still occur in patients with persistent severe atrial stasis. Case summary An 86-year-old woman was admitted with severe acute decompensated heart failure and a low-output state. She had long-standing persistent atrial fibrillation and had undergone bioprosthetic mitral valve replacement with surgical left atrial appendage resection for rheumatic mitral stenosis one year earlier. She received warfarin for the first 3 months after surgery, followed by edoxaban 30 mg once daily; medication reconciliation on admission suggested suboptimal adherence. Contrast-enhanced computed tomography on Day 2 showed two giant left atrial filling defects. Pretreatment laboratory findings yielded an International Society on Thrombosis and Haemostasis overt disseminated intravascular coagulation score of 6; antithrombin activity was 69.4%, and no overt bleeding was present. Unfractionated heparin (UFH) and heart failure therapy were initiated; fresh-frozen plasma and antithrombin concentrate were administered. Coagulation variables improved, and the filling defects disappeared by Day 39 during ongoing UFH and heart failure therapy, without systemic embolism. After stabilization, warfarin therapy was reintroduced with adherence support. Discussion In this case, severe rheumatic atrial remodelling, marked left atrial enlargement, persistent atrial fibrillation, impaired forward flow, and uncertain anticoagulant exposure probably contributed to giant left atrial cavity thrombus formation despite prior appendage resection. This case highlights that surgical left atrial appendage resection does not eliminate the risk of left atrial cavity thrombosis when severe atrial stasis persists.
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Akima et al. (2026) conducted a case report in Giant left atrial thrombi in rheumatic heart disease with persistent atrial fibrillation and acute decompensated heart failure (n=1). Unfractionated heparin, heart failure therapy, fresh-frozen plasma, and antithrombin concentrate was evaluated on Resolution of giant left atrial filling defects. Unfractionated heparin and heart failure therapy resolved two giant left atrial thrombi by Day 39 without systemic embolism in an 86-year-old woman with prior appendage resection.
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