Atrial Fibrillation, Left Atrial Clot, AntiCoagulation for Stroke
Prevention, and Recurrent Gastrointestinal Bleeding: The Value of
an Implantable Loop Recorder
Mohammad Umar Farooq
D. A. Neville Mascarenhas
74-year-old male with history of recurrent life-threatening gastrointestinal bleeding, presented with atrial fibrillation (AF). He was started on oral anticoagulation (OAC). Initial TEE revealed a left atrial clot. After 3 months of treatment with OAC, repeat TEE revealed no left atrial clot. The patient was started on oral amiodarone and electrically cardioverted. An implantable loop recorder (ILR) was placed to monitor AF burden. OAC was discontinued when ILR revealed only NSR for 3 months, and patient remains asymptomatic in NSR to date. ILR monitored rhythm control can be used to safely discontinue OAC in patients at high risk for bleeding.
A 74-year-old male, with a history of coronary artery disease and hypertension presented with symptomatic atrial fibrillation (AF) of unknown duration, was started on rivaroxaban (xarelto), a target specific oral anticoagulant (TSOAC) for stroke prevention. However, due to a history of recurrent life threatening gastrointestinal (GI) bleeding from the anastomotic site of a gastric bypass surgery that was performed previously, the patient was not considered to be a candidate for long-term TSOAC.
After four weeks of TSOAC, the patient underwent a transesophageal echocardiogram (TEE), which unfortunately revealed a left atrial clot, despite being on a TSOAC (Figure 1), and cardioversion was deferred. The patient was continued on a TSOAC without the need for rate control agents. A repeat TEE was performed at 3 months demonstrating resolution of the previously seen atrial clot (Figure 2). Left atrial appendage (LAA) closure device was considered as a more definitive long-term solution, and referral made to a tertiary care facility for this procedure. The patient was unable to follow up the tertiary care center.
Subsequent to the TEE, he was started on amiodarone, a potent oral antiarrhythmic agent (OAA), and electrically cardioverted to normal sinus rhythm two weeks later. Post-cardioversion, an implantable loop recorder (ILR) Medtronic REVEAL XT, was placed subcutaneously for continuous multichannel ECG recording and monitoring of the AF burden. After the ILR recordings showed only NSR and no AF for more than 3 months, the TSOAC was discontinued. The patient has remained asymptomatic on OAA, and regular monthly ILR checks for greater than one year have revealed no further episodes of AF to date.
Atrial Fibrillation is most common sustained dysrhythmia and it increases the risk of developing an acute stroke and congestive heart failure. One of the mainstays for treatment involves long-term oral anticoagulation for stroke prophylaxis[1, 2]. The increasing incidence and prevalence of this medical condition has led to more clinicians prescribing oral anticoagulants. Unfortunately, the use of OACs has lead to an increasing number of patients developing bleeding complications[4, 5].
A growing problem being encountered is that many patients are not suitable for long- term anticoagulation. A history of recurrent GI bleeding precluded our patient from indefinite OAC. In such a patient, percutaneous transcatheter closure of the LAA may provide an alternative option. It is important to note that this technology may not be accessible to all patients. Based on our experience with this patient, we propose that a strategy comprising of ILR monitored rhythm control with short term OAC may be an alternative option in lieu of closure devices in AF patients who are at increased risk for bleeding.
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