Percutaneous left atrial appendage closure in patients with prior intracranial bleeding and thromboembolism

Background: Percutaneous left atrial appendage closure (LAAC) is an alternative treatment in atrial fibrillation patients with contraindication to oral anticoagulation. However, patient selection criteria for LAAC are debated.

Objective: The purpose of this study was to evaluate the outcome after LAAC in patients with prior intracranial bleeding and thromboembolism.

Methods: Consecutive patients with atrial fibrillation and prior intracranial bleeding who underwent LAAC from February 2009 to August 2018 at the Turku University Hospital, Finland, were included in a prospective registry. Patients were followed through clinical visits and annual phone calls up to 5 years.

Results: Overall 104 patients (mean age 73 ± 7 years; 30% women; CHA₂DS₂-VASc score 4.7 ± 1.4; HAS-BLED score 3.3 ± 0.9) with atrial fibrillation and prior intracranial bleeding underwent successful LAAC using mainly (n = 102) Amplatzer devices. Median time from intracranial bleeding to LAAC was 7 months, and median follow-up 3.6 years. Antithrombotic treatment was ≤6 months in 71 patients (68%), and 48 patients (46%) received aspirin or clopidogrel alone. The rates of thromboembolism and intracranial bleeding (per 100 patient-years) were 3.4 and 1.9, respectively. In 39 patients with previous thromboembolism, the rate of thromboembolism was 3.6 per 100 patient-years (95% confidence interval 1.5-7.0), yielding a 69% relative risk reduction with respect to predicted risk based on median CHA₂DS₂-VASc score. Overall, rates of thromboembolism and intracranial bleeding were broadly similar in patients with and those without prior thromboembolism.

Conclusion: Percutaneous LAAC with minimized antithrombotic treatment was demonstrated to be a valid treatment option in high-risk patients with prior intracranial bleeding and thromboembolism.