Results: A 62-year-old female who had a history of end stage renal disease (ESRD) with dialysis was referred to our electrophysiology department due to paroxysmal atrial fibrillation (AF). Anticoagulation therapy with warfarin was started, because her CHADS2-VASc score was 4 (hypertension, diabetes, congestive heart failure, and female gender) as well as amiodarone for rhythm control. Trans-esophageal echocardiography was performed which revealed thrombus in left atrial appendage (LAA). Tachycardia-bradycardia syndrome was documented, therefore, catheter ablation was planned. Follow up TEE identified still remained thrombus despite approximately 1 year of anticoagulation therapy with warfarin. Therefore, warfarin was switched to the direct factor Xa inhibitor, apixaban 5mg bid. After four months of apixaban treatment, TEE revealed complete resolution of LAA thrombus. Finally, catheter ablation was performed without any complication and the patient has been in sinus rhythm thereafter under continued anticoagulant treatment with apixaban. Neither thromboembolic nor bleeding events did not occur during follow up for > 9 months.
Conclusion: Factor Xa inhibitor, apixaban, can successfully and safely resolve the LAA thrombus refractory to warfarin in patients with ESRD requiring dialysis.