Systemic and cerebral thromboembolism is one of the most feared complications of AF. Although available data suggest that the risk of systemic embolism in elective cardioversion is low, stroke is clearly a devastating complication.
We present a case of a patient with some critical features to highlight concerns about the standard of care in atrial fibrillation, anticoagulation and programmed cardioversion.
Even though it isn’t mandatory, pre-procedural TOE is the gold standard for detecting LAA thrombus and it should be considered in patients undergoing scheduled cardioversion after recommended 3 weeks of proper anticoagulation.
Moreover, the right management strategy in LAA thrombosis persistence despite proper anticoagulation isn’t univocal. Continuing the allocated anticoagulant over time, along with serial imaging, it’s a suitable solution.

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