Periprocedural Off-label Use of Rivaroxaban in Patient with Atrial Fibrillation and a Persistent Left Atrial Appendage Thrombus Despite Standard Anticoagulation Therapy: A Case Report

Atrial fibrillation (AF) is a common cardiac arrhythmia characterized by irregular and rapid heart rates, which may lead to various complications, such as stroke, heart failure, and thrombus formation.One particular complication, the development of a left atrial appendage thrombus, increases the risk of thromboembolic events, posing significant health risks to affected individuals.Patients with atrial fibrillation with a left atrial appendage thrombus should receive oral anticoagulation with a non-vitamin K antagonist oral anticoagulant (NOAC), such as rivaroxaban in a standard dose of 15 mg or 20 mg, according to creatinine clearance.However, these guidelines do not provide clear instructions on managing patients with a left atrial appendage thrombus who have already been anticoagulated with 20 mg rivaroxaban for 21 days without thrombus resolution prior to cardioversion.In light of this, we attempted an off-label treatment approach by administering a double dose of rivaroxaban (15 mg twice daily) to a patient presenting with AF and a persistent left atrial appendage thrombus.This case report explores this innovative off-label treatment approach, emphasizing the importance of effective management strategies to mitigate the associated complications and improve patient outcomes.This case report describes a patient with atrial fibrillation and a left atrial appendage thrombus who underwent successful cardioversion after receiving 15 mg of rivaroxaban twice daily as an off-label treatment.The patient well tolerated the increased frequency of administration.This case report suggests that using 15 mg of rivaroxaban twice daily for 14-21 days as an off-label treatment may be viable for patients with atrial fibrillation and a persistent left atrial appendage thrombus despite standard anticoagulation therapy.Clinicians should consider this approach when developing treatment plans for these patients, especially when traditional management strategies have proven ineffective and while keeping in mind the findings of the X-VERT study.