Dissolution of large intracardiac thrombus, potential role of the emerging oral fibrinolytic agent
AbstractIntracardiac thrombus may persist in some cases even after anticoagulant therapy. This opens a possibility to add a potent thrombolytic agent into therapeutic regimen without increasing bleeding risk any further. Increasing evidence showed a promising efficacy and safety of oral fibrin specific lumbrokinase as a thrombolytic agent. To the best of our knowledge, report of the use of lumbrokinase on intracardiac thrombus is limited. We reported two cases of intracardiac thrombi. In first patient, after two-month therapy with lumbrokinase, the previous 8 cm2 left atrial thrombus was completely disappeared. Second patient had left ventricular thrombus due to low left ventricular ejection fraction caused by coronary artery disease. A significant dissolution in thrombus size on repeated follow-up was found. Both patients did not experience any significant adverse effect. This case series aims to present the potential use of lumbrokinase as as oral antithrombotic therapy in intracardiac thrombus.
Karthikeyan G, Thachil A, Sharma S, Kalaivani M, Ramakrishnan L. Elevated high sensitivity CRP levels in patients with mitral stenosis and left atrial thrombus. Int J Cardiol. 2007;122(3):252–4. http://dx.doi.org/10.1016/j.ijcard.2006.11.081
Manning WJ, Silverman DI, Keighley CS, Oettgen P, Douglas PS. Transesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5-year study. J Am Coll Cardiol. 1995;25(6):1354–61. http://dx.doi.org/10.1016/0735-1097(94)00560-D
Zotz RJ, Pinnau U, Genth S, Erbel R, Meyer J. Left atrial thrombi despite anticoagulant and antiplatelet therapy. Clin Cardiol. 1994;17(7):375–82. http://dx.doi.org/10.1002/clc.4960170707
Lip GY. Intracardiac thrombus formation in cardiac impairment: the role of anticoagulant therapy. Postgrad Med J. 1996;72(854):731–8. http://dx.doi.org/10.1136/pgmj.72.854.731
Wolf PA, Dawber TR, Thomas HE Jr, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study. Neurology. 1978;28(10):973–7. http://dx.doi.org/10.1212/WNL.28.10.973
Malik R, Alyeshmerni DA, Wang Z , Goldstein SA, Torguson R, Lindsay J, et al. Prevalence and predictors of left atrial thrombus in patients with atrial fibrillation: is transesophageal echocardiography necessary before cardioversion? Cardiovasc Revasc Med. 2015;16(1):12–4. http://dx.doi.org/10.1016/j.carrev.2014.12.009
Srimannarayana J, Varma RS, Satheesh S, Anilkumar R, Balachander J. Prevalence of left atrial thrombus in rheumatic mitral stenosis with atrial fibrillation and its response to anticoagulation: a transesophageal echocardiographic study. Indian Heart J. 2003;55(4):358–61.
Fukuda S, Watanabe H, Shimada K, Aikawa M, Kono Y, Jissho S, et al. Left atrial thrombus and prognosis after anticoagulation therapy in patients with atrial fibrillation. J Cardiol. 2011;58(3):266–77. http://dx.doi.org/10.1016/j.jjcc.2011.06.009
Jaber WA, Prior DL, Thamilarasan M, Grimm RA, Thomas JD, Klein AL, et al. Efficacy of anticoagulation in resolving left atrial and left atrial appendage thrombi: a transesophageal echocardiographic study. Am Heart J. 2000;140(1):150–6. http://dx.doi.org/10.1067/mhj.2000.106648
Meurin P, Brandao Carreira V, Dumaine R, Shqueir A, Milleron O, Safar B, et al. Incidence, diagnostic methods, and evolution of left ventricular thrombus in patients with anterior myocardial infarction and low ventricular ejection fraction: a prospective multicenterstudy. Am Heart J. 2015;170(2):256–62. http://dx.doi.org/10.1016/j.ahj.2015.04.029
Mihara H, Sumi H, Yoneta T, Mizumoto H, Ikeda R, Seiki M, et al. A novel fibrinolytic enzyme extracted from the earthworm, Lumbricus rubellus. Jpn J Physiol. 1991;41(3):461–72. http://dx.doi.org/10.2170/jjphysiol.41.461
Pan R, Zhang ZJ, He RQ. Earthworm protease. Appl Environ Soil Sci. 2010;2010:1–13. http://dx.doi.org/10.1155/2010/294258
Jin L, Jin H, Zhang G, Xu G. Changes in coagulation and tissue plasminogen activator after the treatment of cerebral infarction with lumbrokinase. Clin Hemorheol Microcirc. 2000;23(2-4):213–8.
Pang SQ, Ding MC, Xie SP, Chai XQ, Deng LY, et al. A clinical study of therapeutic effectiveness in treating ischemic cerebrovascular disease with lumbrokinase. Chin J Neurol Psychiatry. 1993;26(4):229–31.
Kasim M, Kiat AA, Rohman MS, Hanifah Y, Kiat H. Improved myocardial perfusion in stable angina pectoris by oral lumbrokinase: a pilot study. J Altern Complement Med. 2009;15(5):539–44. http://dx.doi.org/10.1089/acm.2008.0506
Ahmed K, Munawar M, Munawar DA, Hartono B. Impact of oral thrombolysis after catheter-based thrombectomy in acute and subacute submassive pulmonary thromboembolism. Chin Med J. 2015;128(3):401–3. http://dx.doi.org/10.4103/0366-6999.150117
Cao YJ, Zhang X, Wang WH, Zhai WQ, Qian JF, Wang JS, et al. Oral fibrinogen-depleting agent lumbrokinase for secondary ischemic stroke prevention: results from a multicenter, randomized, parallel-group and controlled clinical trial. Chin Med J. 2013;126(21):4060–5.
Verma MK, Pulicherla KK. Lumbrokinase – a potent and stable fibrin–specific plasminogen activator. Int J Bio-Sci Bio-Tech. 2011;3(2):57–70.
Angjushev MK, Lazarevska M. Left atrial and left atrial appendage mass diagnosed by cardiac imaging: a case report. Arch Cardiovasc Imaging. 2014;2(1):e15633. http://dx.doi.org/10.5812/acvi.15633
Silaruks S, Thinkhamrop B, Tantikosum W, Wongvipaporn C, Tatsanavivat P, Klungboonkrong V. A prognostic model for predicting the disappearance of left atrial thrombi among candidates for percutaneous transvenous mitral commissurotomy. J Am Coll Cardiol. 2002;39(5):886–91. http://dx.doi.org/10.1016/S0735-1097(02)01686-8
Kim CH, Park SW, Zo JH, Oh BH, Lee MM, Seo JD, et al. Evolution of left atrial thrombus with anticoagulant therapy-follow-up by transesophageal echocardiography. Korean J Intern Med. 1995;10(2):143–5. http://dx.doi.org/10.3904/kjim.19184.108.40.206
Feng SQ, Ting ZA. Lumbrokinase versus warfarin in treating left atrial thrombosis. J Med Forum. 2006;27(13):110.
Camm AJ, Lip GY, De Catarina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the Europan Heart Rhythm Association. Eur Heart J. 2012;33(21):2719–47. http://dx.doi.org/10.1093/eurheartj/ehs253
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