1Asklepios Klinik St. Georg Kardiologie & internistische Intensivmedizin Hamburg, Deutschland; 2Asklepios Klinik Altona Kardiologie und Internistische Intensivmedizin Hamburg, Deutschland; 3Asklepios Klinik St. Georg Interventionelle Kardiologie und Elektrophysiologie Hamburg, Deutschland
Introduction: Left Atrial Appendage Closure (LAAC) reduces stroke risk in patients with atrial fibrillation (AF). Limited data is available regarding LAAC in patients with previous or present LAA thrombus. Here we evaluate the feasibility of LAAC in this setting.
Methods: In this retrospective study, we analysed the medical records of all consecutive patients undergoing LAAC between 10thNovember 2017 and 15th May 2023 at two centers. A total of 31 patients with pre-interventional (group 1) or peri-interventional (group 2) LAA thrombus were identified. The primary objective was the occurrence of peri-interventional complications or severe adverse events during regular clinical follow-up after implantation including routine transesophageal echocardiography after 3 months.
Results: 31 patients with a mean age of 71±8 years (42% women) were included. 20/31 (65%) patients had a history of a LAA thrombus, showing no thrombus prior to implantation, and 11/31 (35%) patients underwent the procedure despite the presence of a LAA thrombus. These patients received at least a 4-week course of oral anticoagulation to reduce LAA thrombus burden yet anticoagulation was unsuccessful to dissolve the thrombus. 2/31 (6.5%) developed a pericardial effusion during the procedure. No peri-interventional stroke was observed. After a median [Q1, Q3] follow-up of 3 [2.75, 6] months, we observed post-procedural device-associated thrombus (DAT) in 2/14 patients (14%) and stroke in 1/14 patients (7%) of group 1. In group 2, 3/11 (27%) patients showed a device thrombus during follow-up, but no stroke was observed.
Conclusion: With an overall low stroke rate, implantation of LAAC in patients with a prior thrombus is feasible. However, patients with prior LAA thrombus appear to have a higher risk of post-procedural DAT. An intensified oral anticoagulation instead of DAPT may be warranted in these patients, weighing out the bleeding risk. Further studies with larger cohorts are mandatory in this setting.
Table 1: Patients characteristics and results
|
Characteristic |
N |
Overall,
N = 31 |
Pre-interventional LAA thrombus, N = 20 |
Peri-interventional LAA thrombus, N = 11 |
p-value1 |
|
Age |
31 |
|
|
|
0.047 |
|
Median [Q1, Q3] |
|
74 [69, 77] |
75 [71, 78] |
70 [63, 74] |
|
|
Sex, % (n) |
31 |
|
|
|
0.28 |
|
female |
|
42 (13) |
50 (10) |
27 (3) |
|
|
Comorbidities |
|
|
|
|
|
|
History of Stroke, % (n) |
31 |
32 (10) |
40 (8) |
18 (2) |
0.26 |
|
Atrial Fibrillation, % (n) |
31 |
|
|
|
0.81 |
|
paroxysmal |
|
13 (4) |
10 (2) |
18 (2) |
|
|
Persistierend or permanent |
|
86.7 (27) |
90 (18) |
82 (10) |
|
|
Prior AF Ablation, % (n) |
23 |
70 (16) |
73 (11) |
62 (5) |
>0.99 |
|
CHA2DS2Vasc-Score, % (n) |
31 |
|
|
|
0.21 |
|
1 |
|
6.5 (2) |
0 (0) |
18 (2) |
|
|
2 |
|
13 (4) |
15 (3) |
9.1 (1) |
|
|
3 |
|
26 (8) |
20 (4) |
36 (4) |
|
|
≥4 |
|
64.7 (17) |
65 (13) |
36.1 (4) |
|
|
Results |
|
|
|
|
|
|
Peri-interventional Complications |
|
|
|
|
|
|
Stroke, % (n) |
31 |
0 (0) |
0 (0) |
0 (0) |
>0.99 |
|
Vascular Complications, % (n) |
31 |
0 (0) |
0 (0) |
0 (0) |
>0.99 |
|
Pericardial Effusion, % (n) |
31 |
6.5 (2) |
5 (1) |
9.1 (1) |
>0.99 |
|
Follow-up: Severe adverse events |
|
N=25 |
N=14 |
N=11 |
|
|
Device thrombus, % (n) |
25 |
20 (5) |
14 (2) |
27 (3) |
0.62 |
|
Stroke, % (n) |
25 |
4.0 (1) |
7.1 (1) |
0 (0) |
>0.99 |
|
1Wilcoxon rank sum test; Fisher's exact test | |||||