Author ORCID Identifier
Astha Prasai: 0000-0002-4412-5038
Abstract
Introduction:
Coumadin ridge, also known as warfarin ridge, is an embryological remnant in the form of a muscular ridge in the left atrium. We present a case of a middle-aged gentleman with prominent Coumadin ridge.
Case:
49 year old male with history of pulmonary embolism (PE) (on Xarelto), attention deficit hyperactivity disorder (ADHD), prior polysubstance use, currently everyday smoker presented to the emergency department with history of shortness of breath and productive cough for 8 weeks. Initially he was treated with doxycycline for bronchitis and later with azithromycin for pneumonia as outpatient. He did not have chest pain, palpitations or limb swelling. On examination, heart sounds were distant and pulsus paradoxus was noted. He underwent computed tomography angiography (CTA) of the chest which revealed moderate left pleural effusion and a large pericardial effusion. Xarelto was held. He underwent pericardial window and thoracocentesis and chest tube placement for left pleural effusion. Intraoperative transesophageal echocardiography (TEE) showed likely thrombus or mass in the left atrial appendage (LAA). Thought to be xarelto failure, he was started on heparin for anticoagulation. He was also suspected to have malignancy given his extensive tobacco smoking history and family history of lung cancer. CT chest and fluid analysis was negative for malignancy. Cardiac magnetic resonance imaging (MRI) showed features suggestive of effusive constrictive pericarditis, left atrium was normal. Repeat TEE showed prominent Coumadin ridge with prominent LAA trabeculation with no mass or thrombus. Xarelto was restarted. Pericardial and pleural fluid analysis was negative for infectious workup including tuberculosis and autoimmune workup was also negative. He was started on colchicine and tapering dose of steroids for constrictive pericarditis. He improved and was discharged home to follow up with cardiology outpatient.
Discussion:
In our case, the echogenic hyperdensity on intraoperative transesophageal echocardiography raised suspicion of mass or thrombus. Our patient was already on Xarelto for pulmonary embolism. Direct oral anticoagulants (DOACs) failure has been reported in only approximately 2.1% of patients in large clinical trials. It is really interesting how coumadin ridge can almost be missed and how our patient was almost deemed to have xarelto failure, highlighting about the importance of being mindful about how the presence of prominent coumadin ridge could be easily mistaken for a pathology when it is not.
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Recommended Citation
Prasai A, Shingada K, AlAli O, Latifi N, Abu Sheikha M, Shan J. A case of a prominent coumadin ridge poses a diagnostic dilemma. Advances in Clinical Medical Research and Healthcare Delivery. 2023; 3(4). doi: 10.53785/2769-2779.1163.