Intracardiac thrombi during warfarin anticoagulation - A case report and a brief literature review

A 78-year-old woman with a history of ischaemic heart disease and permanent atrial fibrillation, on treatment with warfarin, was admitted to the Emergency Department because of paroxysmal nocturnal dyspnoea. Instrumental findings indicated an early phase of acute heart failure. The latest INR value was 3.64, and previous available INR values were all within the therapeutic range (2-3). A transthoracic 2D echocardiographic examination showed left ventricular dilatation and a severe reduction in systolic function. An echogenic pedunculated mass was observed in the left atrium, adherent to the interatrial septum. Twelve hours later, the patient reported the acute onset of pain in the left arm. A thromboembolic occlusion of the left humeral artery was documented, and this was acutely treated with Fogarty embolectomy. In the first hour after this intervention, a series of relapsing thromboembolic events led to the final amputation of the arm. Warfarin was discontinued and treatment with dabigatran 150 mg BID enacted, followed by the disappearance of the thrombotic mass and clinical resolution.