Left atrial appendage percutaneous closure with a watchman device in patients with a contraindication to long-term oral anticoagulation. One-year follow-up

Abstract

Trans-catheter left atrial appendage (LAA) occlusion is recommended for stroke prevention in patients with non-valvular atrial fibrillation (AF), a CHA2DS2VASc score ≥ 4 (Score) and a contraindication to long-term anticoagulation. The PROTECT AF trial demonstrated that LAA closure with the Watchman (WM) device (Boston Scientific, MA, USA) was non-inferior to warfarin therapy. However, patients included received concomitant warfarin for 6 weeks after WM implantation. The ASAP study suggested that LAA closure with the WM without a warfarin transition was a reasonable alternative for patients with contraindications (CI) to oral anticoagulation (OAC). Our aim was to evaluate this strategy at one year in our institution. From December 2013 to April 2017, the procedure was performed in 74, successfully in 70 (95%). All patients were alive, event free at 45 days for the first on site check-up. A one year follow-up was obtained in 50 patients, 32 male (64%), mean age 77 year (51-93), with a CH2DS2VASc score = 5 (3–9), and HASBLED score = 4.5 (3–9). Previous embolic stroke was reported in 23 (46%). Contraindication for OAC was a hemorrhagic event in all, neurologic in 20 (40%) gastroenterologic in 24 (48%). After WM implantation, 26 received Aspirin or Clopidogrel (46%), 16 both (32%) and 8 none (16%). At 45 days, dual anti-platelet therapy was renewed in 19 (38%) with severe coronary. At 1 year, no thromboembolic event was reported. Twelve patients died (24%), 2 after cerebral hemorrhage, 1 terminal liver failure, 1 cancer, 2 pneumonia, 6 suddenly. For the later with multivessel disease, ischemic origin was suspected. In patients with a high risk of embolic stroke and permanent CI to OAC, LAA closure may be performed with no anticoagulation. Nevertheless this population is at high risk of short-term death from other origin. A better evaluation of the prognosis should be done before planning the procedure.