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Role of Left Atrial Appendage Closure in Managing Patients With High Risk of Stroke & Bleeding: Perspectives From HRS 2021

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The annual meeting of the Heart Rhythm Society concluded in Boston last week. This was my first time attending a major medical conference since the start of the COVID-19 pandemic. Attendance for the conference was about one-third of the usual and was especially affected by the absence of international members of the heart rhythm community. However, the meeting still offered plenty of value in terms of learning about new advancements and networking opportunities.

One of the major themes of the conference was the management of left atrial appendage (LAA) associated risk of thromboembolism. The LAA is a major source of stroke in patients with atrial fibrillation and elevated CHADS2-VASC score. Left atrial appendage closure (LAAC) is an established alternative to anticoagulation therapy in patients who are suitable for short-term anticoagulation but have contraindications to long-term anticoagulation.

Patients with prior history of intracranial hemorrhage (ICH) are a unique group where even short-term anticoagulation can be dangerous, and these patients were not included in Watchman device trials. Garg et al. presented data on the safety and efficacy of LAAC in patients with prior ICH. They performed a meta-analysis of seven retrospective studies that included 407 ICH patients who underwent LAAC. Acute procedure success was achieved in 98.5% of patients. Only 26.3% of patients received oral anticoagulants post-LAAO, while the rest received single or dual antiplatelet therapy. Overall, the per-procedural complications rate was similar to the general population of LAAC. This data reinforces the safety of LAAC in patients with prior ICH despite not being able to use standard antithrombotic therapy in the immediate post-operative period.

The other challenging group is patients with persistent LAA thrombus despite attempts at dissolution with tolerated anticoagulation therapy. These patients have very limited treatment options and often represent the highest risk group for stroke and thromboembolism. We presented our experience in taking care of three such patients over two years. Three patients underwent implantation of the Watchman device despite persistent LAA thrombus. The first patient had a Watchman 2.5 device, and the other two underwent a Watchman flex device implant. All implants were performed with concurrent use of the Sentinel cerebral protection system (CPS). There were no periprocedural cerebrovascular events, and all three patients were implanted successfully. Follow-up imaging at a six-week interval showed a well-seated device and no evidence of device-related thrombus or peri-device leaks. The first patient had a follow-up CT at two years, and it showed a well-functioning device with no thrombus.

Another study evaluated Long-term Half-dose Novel Oral Anticoagulation Versus Standard Antithrombotic Therapy After Left Atrial Appendage Occlusion with A Watchman Device. Della Rocca et al. presented data from 555 patients showing that after successful Watchman implantation, long-term half-dose NOAC significantly reduced the risk of the composite endpoint of DRT, TE, and major bleeding events compared to a standard, antiplatelet-based, antithrombotic therapy.

Another area of significant interest in understanding the role of LAAC as a first-line treatment option in patients without contraindication to direct oral anticoagulants (DOAC). CHAMPION-AF & CATALYST are two ongoing clinical trials that seek to assess non-inferiority of Watchman Flex or Amulet LAA closure devices over DOAC therapy in patients without contraindication to anticoagulation. Future results of these studies were a common point of discussion among the attendees suggesting a great deal of anticipation & optimism in the heart rhythm community.

These presentations and other accumulating evidence suggest that LAAC therapy is gaining momentum in the prevention of atrial fibrillation-related strokes. There would be a role for both percutaneous and surgical options in different patient populations. I look forward to HRS 2022 in San Francisco, where we may have further evidence regarding the role of LAAC in reducing stroke risk in AF patients.

Dr. Sandeep Goyal is employed by Piedmont Healthcare. They have no conflicts of interest to report.

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