Left Atrial Appendage Closure in Atrial Fibrillation for Stroke Prevention in Patients with Contraindication to Oral Anticoagulation. Single Center Experience

Ilya Litovchick MD, Sa`ar Minha MD, Inna Yofik MD, Zvi Vered MD FACC FESC, Daniela Alon MsC, Alberto Hendler MD FSEC

Background: AF patients at the highest risk for embolic stroke also experience the greatest risk of hemorrhagic complications of anticoagulant use. The PROTECT AF trial revealed that LAA closure using the Watchman device (actually FDA approved) was non-inferior to Warfarin for preventing stroke in patients CHADS21. However, these patients were treated with Warfarin post-implant until TEE demonstrated complete LAA exclusion at 6 weeks. Due to the pressing need for strategies that can prevent stroke in patients with contraindication to anticoagulants we started our program in anticoagulation-contraindicated patients.

Methods: Since October 2013 till now, after TEE screening for availability in 29 patients with CHADS2 and contraindication for oral anticoagulants, we performed 25 implants in standard fashion. Post-implant, patients were discharged on 6 mo clopidogrel and life-long aspirin. Follow up TEE was performed at 50 days and 12 month.

Results: 25 patients were successfully implanted. The mean age was 72.57.4 years. The prevalence of stroke risk factors was: Age in 75%, HTN in 85%, DM in 32% and previous stroke/TIA in 65%, CHF in 5%. The mean CHADS2 score was 2.8.

The reason for anticoagulation was hemorrhagic tendencies (75%), frailty with high fall risk (4%) and other (21%). Watchman implantation was successful in 85%. At 2.5 years follow-up there were no strokes and one case of device related thrombus by 50 days TEE, that was successfully resolved by short course OAC.

Conclusion: Watchman device implantation without an anticoagulant transition is safe and effective in AF patients with contraindications to even short term oral anticoagulation.