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