Left atrial appendage closure. Monocentric registry of the first 100 cases: Indications, peri-operative anticoagulation strategies, complications and follow-up

Abstract

According to the French National Authority for Health, percutaneous left atrial appendage closure (LAAC) is recommended for patients with a high risk of stroke (CHA2DS2-VASC ≥ 4) and contraindicated to long-term anticoagulation (AC) due to high bleeding risks. The aim of our monocentric registry was to evaluate our experience after the first 100 procedures. A total of 100 patients were prospectively included from Sept 2013 to Sept 2017. We analyzed data from the procedures considering indications, procedural complications, postoperative antithrombotic treatment and midterm outcome. Procedures took place in a hybrid room under general anesthesia and TEE guidance with 5000UI IV heparin before transseptal puncture. Follow-up was assessed by serial TEE and/or CT scan. Over 4 years, 100 patients underwent LAAC and followed over 27 ± 14 months. Mean age was 74.7 ± 7.8 years (77 M, 23 F) with mean CHA2DS2-VASC 4.6 ± 1.3 and HAS-BLED 2.5 ± 0.9. A total of 84 patients had a history of severe hemorrhage (54% of intracranial and 27% gastrointestinal). A subgroup of 22 patients had a CHA2DS2-VASC score < 4 but had a high bleeding risk. Indications for LAAC were in agreement with ESC guidelines in 96, HAS in 78 and FDA in 40 patients. A total of 40 Watchman™ and 58 ACP™/Amulet™ devices were implanted with 13 post-LAAC complications (6 puncture site, 2 failed implantations with Watchman, 2 pericardial effusions, 1 tamponade and 2 hemorrhages not requiring transfusion). Aspirin as the only antiplatelet therapy (APT) was the major postoperative strategy (74%). No treatment was prescribed in 3. Mean hospital stay was 2 nights. During follow-up we observed 2 asymptomatic device thrombus, 2 intracranial bleeds, 3 ischemic strokes i.e. 0.75%/pt-year and 6% periprosthetic leak. LAAC is a safe and efficient strategy. Management of APT/AC post-LAAC is not yet well defined and should be studied further. Patients with CHA2DS2-VASC < 4 but very high bleeding risk may be an indication for LAAC.