Left Atrial Appendage Thrombus Resolution with Reduced Dose Apixaban.

A 63 year old woman with a history of persistent atrial fibrillation and CHADSVASC score of 2, suffered a massive stroke with a hemorrhagic transformation, 2 days following an appendectomy and reversal of warfarin anticoagulation with vitamin K. A left atrial appendage occlusive device (LAAOD) was considered for stroke prevention given the risk of recurrent cerebral hemorrhage. A transesophageal echocardiography (TEE) however, revealed left atrial appendage (LAA) clots which precluded the use of a LAAOD. A computed tomography revealed only partial resolution of the right hemispheric hematoma. Apixaban 2.5 mg twice daily was successful in resolving the LAA clots within 2 months without aggravating her cerebral hematoma which continued to resolve. This is the first case, to our knowledge showing reduced-dose Apixaban to completely resolve left atrial thrombus. Our case also addresses the issue of bridging following reversal of warfarin anticoagulation with vitamin K.