Complete Resolution of Pacemaker Lead Thrombus with Warfarin Following Direct Oral Anticoagulant Failure: A Case Report

Pacemaker lead thrombosis is a recognized complication of cardiac implantable electronic devices (CIEDs) that occurs due to endothelial trauma and increased blood turbulence caused by the foreign material of the pacemaker leads themselves [1]. The incidence of intracardiac thrombi associated with CIEDs ranges from 1.4% to 30% depending on the imaging modality and patient population studied, with the highest rates identified incidentally during lead extraction or ablation procedures [1,2]. While many cases remain clinically silent, symptomatic pacemaker lead-associated thrombosis can present with nonspecific symptoms and carries serious potential complications including pulmonary embolism and systemic thromboembolism, necessitating prompt diagnosis and treatment [1,2]. Anticoagulation therapy has emerged as the mainstay of management for most intracardiac pacemaker lead thromboses [3]. Current evidence indicates that warfarin prophylaxis lowers the incidence of venous lesions in high-risk patients, particularly those with left ventricular ejection fraction of 40% or less or multiple pacemaker leads [1,4]. Additionally, warfarin therapy has demonstrated efficacy in resolving established pacemaker lead thrombi, with resolution rates of 75 to 80% in patients initiated on anticoagulation [5]. However, there remains a notable gap in the literature regarding the management of patients with pacemaker lead thrombosis who develop thrombus while on DOAC therapy and require transition to alternative anticoagulation. This case report contributes to this body of knowledge by documenting the successful resolution of pacemaker lead thrombosis following transition from rivaroxaban to warfarin therapy.