Abramovitz Fouks Avia, Yaghi Shadi, Selim Magdy H, Gökçal Elif, Das Alvin S, Rotschild Ofer, Silverman Scott B, Singhal Aneesh B, Kapur Sunil, Greenberg Steven M, Gurol Mahmut Edip
Neurology, Massachussets General Hospital, Harvard Medical School, Boston, MA, USA.
Neurology, Brown University, Warren Alpert Medical School, Providence, RI, USA.
Stroke Vasc Neurol. 2025 Feb 25;10(1):120-128. doi: 10.1136/svn-2024-003143.
The occurrence of acute ischaemic stroke (AIS) while using oral anticoagulants (OAC) is an increasingly recognised problem among nonvalvular atrial fibrillation (NVAF) patients. We aimed to elucidate the potential role of left atrial appendage closure (LAAC) for stroke prevention in patients with AIS despite OAC use (AIS-despite-OAC).
We retrospectively collected baseline and follow-up data from consecutive NVAF patients who had AIS-despite-OAC and subsequently underwent endovascular LAAC, between January 2015 and October 2021. The primary outcome measure was the occurrence of AIS after LAAC, and the safety outcome was symptomatic intracerebral haemorrhage (ICH).
29 patients had LAAC specifically because of AIS-despite-OAC. The mean age at the time of the procedure was 73.4±8.7, 13 were female (44.82%). The mean CHADS-VASc score was 5.96±1.32, with an expected AIS risk of 8.44 per 100 patient-years. 14 patients (48%) had two or more past AIS-despite-OAC. After LAAC, 27 patients (93.10%) were discharged on OAC which was discontinued in 17 (58.62%) after transoesophageal echocardiogram at 6 weeks. Over a mean of 1.75±1.0 years follow-up after LAAC, one patient had an AIS (incidence rate (IR) 1.97 per 100 patient-years). One patient with severe cerebral microangiopathy had a small ICH while on direct OAC and antiplatelet 647 days after LAAC.
LAAC in AIS-despite-OAC patients demonstrated a low annual AIS recurrence rate in our cohort (1.97%) compared with the expected IR based on their CHADS-VASc scores (8.44%) and to recent large series of AIS-despite-OAC patients treated with OAC/aspirin only (5.3%-8.9%). These hypothesis-generating findings support randomised trials of LAAC in AIS-despite-OAC patients.
在非瓣膜性心房颤动（NVAF）患者中，使用口服抗凝药（OAC）时发生急性缺血性卒中（AIS）是一个日益受到关注的问题。我们旨在阐明左心耳封堵术（LAAC）在预防尽管使用OAC但仍发生AIS的患者（AIS-尽管-OAC）卒中方面的潜在作用。
我们回顾性收集了2015年1月至2021年10月期间连续的AIS-尽管-OAC且随后接受血管内LAAC的NVAF患者的基线和随访数据。主要结局指标是LAAC后AIS的发生情况，安全性结局是有症状的颅内出血（ICH）。
29例患者因AIS-尽管-OAC而专门接受了LAAC。手术时的平均年龄为73.4±8.7岁，13例为女性（44.82%）。平均CHADS-VASc评分为5.96±1.32，每100患者年发生AIS的预期风险为8.44。14例患者（48%）既往有两次或更多次AIS-尽管-OAC。LAAC后，27例患者（93.10%）出院时继续使用OAC，其中17例（58.62%）在6周经食管超声心动图检查后停用。在LAAC后的平均1.75±1.0年随访中，1例患者发生了AIS（发病率（IR）为每100患者年1.97）。1例患有严重脑微血管病的患者在LAAC后647天接受直接OAC和抗血小板治疗时发生了小的ICH。
在我们的队列中，AIS-尽管-OAC患者的LAAC显示出较低的年度AIS复发率（1.97%），与基于他们的CHADS-VASc评分的预期IR（8.44%）以及最近仅接受OAC/阿司匹林治疗的大量AIS-尽管-OAC患者系列（5.3%-8.9%）相比。这些产生假设的发现支持对AIS-尽管-OAC患者进行LAAC的随机试验。
