Obesity is a worldwide epidemic condition at high risk for AF development; nevertheless, obese patients are underrepresented in RCTs of anticoagulant agents. Robust evidence assessing efficacy of DOACs in these patients is lacking and, to date, major Associations do not recommend DOACs in patients > 120 Kg (BMI>40 Kg/m2). The use of implantable cardiac devices has substantially increased in recent years; among potential complications are sterile intracardiac clots on the leads, typically discovered as incidental echocardiographic findings.
46 ys old male patient, III degree obesity (160 Kg,BMI 51 Kg/m2), ex-smoker. In 2012, acute heart failure and diagnosis of non-ischemic dilated cardiomyopathy (EF 20%). During the follow-up by a tertiary Center, in 2021 he was implanted with single-chamber ICD in primary prevention. At presentation, HFrEF pharmacological therapy was optimal (ARNI,SLGT2i,MRA,B-blocker). He came to the ED complaining of weakness; ECG showed atrial fibrillation, mean ventricular rate 160 bpm. CHA2DS2-VASc was 1. Anticoagulation with subcutaneous enoxaparin 10000UI twice daily was started. He was admitted to the cardiology ward and remained hemodynamically stable, with persistence of AF. Transesophageal echocardiography excluded thrombus in the left atrial appendage; unexpectedly, a filamentous, floating formation of about 30mm on the atrial side of the ICD lead was observed, compatible with a thrombotic formation, since the patient, afebrile, didn’t show any suggestive sign of endocarditis nor past history of infection; blood cultures, CRP and Procalcitonin were negative. In the absence of any shunt at the level of interatrial septum, it was felt safe to proceed to electrical cardioversion, able to restore sinus rhythm with a single 250J biphasic synchronized shock. Oral anticoagulation with warfarin was started, since no DOAC was considered adequate for effective anticoagulation. The following in hospital course and post-discharge weeks were uneventful, despite unstable INR values. Follow-up is ongoing; the patient has not yet repeated imaging to check for mass resolution.
Stroke prevention in severely obese patients with AF is challenging and points toward warfarin use, as the evidence of DOACs efficacy is sparse. In our case, anticoagulant choice was also motivated by concomitant presence of a lead thrombus, a scenario in which optimal management and anticoagulation regimen are not clearly established yet.