Case
74-year-old male with history of chronic atrial fibrillation presents
with 5 days of abdominal pain and dyspnea. 7 months prior, he underwent
placement of a Watchman device due to nonadherence with apixaban 5mg
twice daily. Transesophageal echocardiogram (TEE) revealed a large
thrombus, measuring 2.9 x 1.9 cm, seated on top of the Watchman device
(Figure 1). At the time of presentation, he was taking aspirin 325 mg
daily. He inadvertently stopped taking aspirin and clopidogrel 2 months
earlier than recommended and had a 10-day interruption of aspirin for
screening colonoscopy. He was discharged on apixaban 5 mg twice daily
and aspirin 325 mg daily. Follow up TEE 4 months later revealed reduced
size of thrombus, measuring 0.70 x 0.86cm (Figure 2).
Atrial fibrillation is the most common cardiac arrhythmia that we face,
affecting millions of people worldwide. It carries the risk of stroke,
especially in those with elevated CHA2DS2-VASc score, necessitating use
of anticoagulation. In those who risk of bleeding outweighs the benefit,
left atrial appendage closure device, such as the Watchman, is a great
alternative and has been shown to be noninferior in the PROTECT AF
study.2 It, however, does carry its own risk such as device-related
thrombus.1