Background: There are conflicting results regarding the safety and efficacy of direct oral anticoagulants (DOACs) in the management of left ventricular thrombus (LVT) compared with the vitamin K antagonist warfarin. Study question: What is the safety and efficacy of DOACs in the management of LVT compared with warfarin? Data source: Randomized clinical trials and cohort studies in the MEDLINE and Cochrane databases from inception till April 4, 2021. Study design: The present analysis is a systematic review and meta-analysis. Desired outcomes were all-cause mortality, complete resolution of LVT, stroke and systemic emboli, and major bleeding. The risk ratio (RR) of the outcomes and 95% confidence intervals (CIs) were calculated using a random-effects modeling approach. Results: Twelve studies with a total of 2322 patients were included. There was no difference between the 2 interventions in the resolution of LVT [RR 0.97 (CI 0.93–1.02)], stroke and systemic embolism [RR 0.95 (CI 0.63–1.45)], bleeding [RR 1.14 (CI 0.81–1.60)], and all-cause mortality [RR 0.99 (CI 0.67, 1.46)]. Conclusions: DOACs and warfarin have comparable safety and efficacy outcomes in the management of LVT.

Subclinical atrial fibrillation (SCAF) episodes are frequently detected in patients with cardiac implantable electronic devices (CIEDs). These asymptomatic arrhythmias are increasingly recognized as potential harbingers of clinical atrial fibrillation and thromboembolic events. However, the management of SCAF—particularly regarding the use of oral anticoagulation (OAC)—remains controversial. This literature review (Medline, Scopus, Goggle scholar, Embase) focuses on using current literature and clinical studies to guide decision-making regarding anticoagulation therapy and other treatment options that can limit complications for patients with SCAF. The decision to initiate anticoagulation in patients with atrial high-rate episodes (AHREs) should be individualized, balancing stroke risk against bleeding potential. Ongoing research and post hoc analyses will further clarify which subgroups may benefit most from therapy, informing future guideline recommendations.

We present a case of Watchman device extrusion from left atrial appendage (LAA) free wall 6 months after implantation in a patient with longstanding persistent atrial fibrillation. A 74-year-old male with longstanding persistent atrial fibrillation of 15 years duration was implanted with a Watchman device as he cannot be on long-term oral anticoagulation due to a history of multiple falls. Six months post implantation, repeat transesophageal echocardiogram revealed a thrombus on the epicardial aspect of LAA and a large posterior pericardial effusion. The patient subsequently underwent surgical removal of both the LAA and the protruding Watchman device. In the case we present, the patient developed a clinically significant pericardial effusion 6 months after the Watchman device implantation, accompanied by left atrial extrusion, which was not reported to our knowledge. Complications of Watchman devices respect no timeline boundaries and should be kept in mind when evaluating cardiac tamponade in patients with an implanted Watchman device.