Left atrial appendage closure in patients with prior intracranial bleeding, safety, efficacy, and timing.

BACKGROUND

Oral anticoagulation (OAC) use increases the risk of intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF) and CHADS-VASc ≥2. Left atrial appendage occlusion (LAAO) is an alternative to OAC, however data about its use in patients with prior ICH is scarce and the timing of its performance is controversial. Furthermore, the long-term outcomes in this group of patients have not been described previously.

OBJECTIVE

To evaluate the safety and efficacy of LAAO in patients with non-valvular AF and prior ICH (CHADS-VASc ≥2) and to determine adequate timing of its performance.

METHODS

This is a multicenter retrospective registry that included 128 patients, whose indication for this procedure was ICH. Patients were divided into two groups: early occlusion (n=31; 24.2%), in which the procedure was performed before 90 days had elapsed after the bleeding, and late occlusion (n=97; 75.8%), after 90 days.

RESULTS

Global procedural success was of 97% (124/128). Procedure-related complications occurred in 4 patients (3.15%): 2 cardiac tamponade, 1 device embolization and 1 transient ischemic attack during hospitalization. There was a significant reduction in the ischemic and bleeding rates compared to expected based on CHADS-VASc and HASBLED scores (93.9% and 89.9% respectively) after a mean follow-up of 73.9±34.1 months. There were no significant differences neither in baseline characteristics between the early and late occlusion groups nor in the procedural success or complications rates. Furthermore, no statistically significant differences were found in mortality, ischemic events, or hemorrhage between the early and late occlusion group.

CONCLUSIONS

Left atrial appendage occlusion is an effective and safe treatment alternative to reduce the risk of ischemic stroke in selected patients with atrial fibrillation and prior intracranial hemorrhage. In this study, we did not find differences regarding safety and efficacy in early closure compared with late closure. Further studies are needed to support early closure to reduce the complications associated with oral anticoagulation withdrawal.