Gonzalez-Calle D, Nombela-Franco L, Gutierrez-Garcia H, Peral V, Mesnier J, Tirado-Conde G, Barrero-Mier A, Morcuende Gonzalez A, O'Hara G, López-Mesonero L, Salinas P, Sanchís L, Cepas-Guillén P, Laffond A, Freixa X, Amat-Santos I, Sanchez P L, Rodes-Cabau J, Cruz-Gonzalez I
Hospital Universitario de Salamanca, CIBERCV, IBSAL, Spain.
Instituto Cardiovascular, Hospital Clínico San Carlos, IdISSC, Madrid, Spain.
Neurologia (Engl Ed). 2025 Sep;40(7):668-675. doi: 10.1016/j.nrleng.2025.07.009.
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.
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.
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.
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.
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.
口服抗凝药（OAC）的使用会增加心房颤动（AF）且CHADS-VASc评分≥2的患者发生颅内出血（ICH）的风险。左心耳封堵术（LAAO）是OAC的替代方案，然而，关于其在既往有ICH患者中的应用数据稀少，且手术时机存在争议。此外，此前尚未描述过这组患者的长期预后情况。
评估LAAO在非瓣膜性AF且既往有ICH（CHADS-VASc评分≥2）患者中的安全性和有效性，并确定合适的手术时机。
这是一项多中心回顾性登记研究，纳入了128例因ICH而接受该手术的患者。患者被分为两组：早期封堵组（n = 31；24.2%），即出血后90天内进行手术；晚期封堵组（n = 97；75.8%），即出血90天后进行手术。
整体手术成功率为97%（124/128）。4例患者（3.15%）发生了与手术相关的并发症：2例心包填塞、1例装置栓塞和1例住院期间短暂性脑缺血发作。平均随访73.9±34.1个月后，与基于CHADS-VASc和HASBLED评分预期的缺血和出血率相比，均有显著降低（分别为93.9%和89.9%）。早期和晚期封堵组在基线特征、手术成功率或并发症发生率方面均无显著差异。此外，早期和晚期封堵组在死亡率、缺血事件或出血方面也未发现统计学显著差异。
左心耳封堵术是一种有效且安全的治疗选择，可降低部分有心房颤动和既往颅内出血患者的缺血性卒中风险。在本研究中，我们未发现早期封堵与晚期封堵在安全性和有效性方面存在差异。需要进一步研究来支持早期封堵以减少与停用口服抗凝药相关的并发症。
