Non-vitamin K antagonist oral anticoagulants for the treatment of intracardiac thrombosis.

Intracardiac thrombus most commonly develops in the left atrial appendage (LAA) and left ventricle (LV) in the setting of atrial fibrillation (AF) and post-myocardial fibrillation (MI), respectively. Current guidelines recommend that patients with post-MI LV or LAA thrombus should be treated with vitamin K antagonist (VKA). However, the use of VKA may be limited by bleeding complications, interactions with various food and drugs, and a narrow therapeutic window requiring frequent monitoring. Thus, non-VKA oral anticoagulants (NOACs) have been attempted as an off-label use for the treatment of intracardiac thrombosis in light of their favorable pharmacologic profile. Until now, therapeutic effect of NOACs on intracardiac thrombosis has not been formally studied in large randomized controlled trials. This article aims to systematically review the literature regarding efficacy and safety outcome of NOACs in the management of intracardiac thrombus. Considering the high rate of complete thrombus resolution and low rate of thromboembolic or hemorrhagic complications, preliminary evidence from case series and reports indicate that NOACs (including factor Xa inhibitors and direct thrombin inhibitors) may be a safe and effective therapeutic option for intracardiac thrombosis, particularly in cases resistant to VKA therapy.