Trans-Catheter Aortic Valve Replacement Thrombus in Patient on Xarelto and Aspirin Resolved Three Months After Warfarin

Trans-catheter aortic valve replacement has been gaining ground since it was performed in 2002. Indications for the procedure are also expanding and are expected to include patients with intermediate risk for perioperative mortality. There are no guidelines on the use of anticoagulation in patients who have undergone trans-catheter aortic valve replacement. We present an interesting case of an 82-year-old gentleman with past medical history of paroxysmal atrial fibrillation with CHA2DS2-VASc (a clinical prediction tool for estimating risk of stroke in patients with atrial fibrillation) score of 3, coronary artery disease, pernicious anemia, and severe symptomatic aortic stenosis who had trans-catheter aortic valve replacement. He was on Xarelto and aspirin, and still developed thrombus on the aortic valve many months after the procedure. The thrombus resolved after few months of anti-coagulation with Coumadin. This case shows that thrombus on the valve can still occur post-procedure even in patients who are on direct oral anticoagulant and aspirin. This calls into question if there is need to anti-coagulate all patients after TAVR procedure with Coumadin for at least 3 - 6 months. As our knowledge of the post-TAVR complications and outcomes continues to grow, we may be able to answer this question in the future, especially with large scale research studies. J Med Cases. 2018;9(8):278-280 doi: https://doi.org/10.14740/jmc3084w