Left atrial appendage closure in patients with atrial fibrillation and acute ischaemic stroke despite anticoagulation

Abstract

Background: The occurrence of acute ischaemic stroke (AIS) while using oral anticoagulants (OAC) is an increasingly recognised problem among nonvalvular atrial fibrillation (NVAF) patients. We aimed to elucidate the potential role of left atrial appendage closure (LAAC) for stroke prevention in patients with AIS despite OAC use (AIS-despite-OAC).

Methods: We retrospectively collected baseline and follow-up data from consecutive NVAF patients who had AIS-despite-OAC and subsequently underwent endovascular LAAC, between January 2015 and October 2021. The primary outcome measure was the occurrence of AIS after LAAC, and the safety outcome was symptomatic intracerebral haemorrhage (ICH).

Results: 29 patients had LAAC specifically because of AIS-despite-OAC. The mean age at the time of the procedure was 73.4±8.7, 13 were female (44.82%). The mean CHA₂DS₂-VASc score was 5.96±1.32, with an expected AIS risk of 8.44 per 100 patient-years. 14 patients (48%) had two or more past AIS-despite-OAC. After LAAC, 27 patients (93.10%) were discharged on OAC which was discontinued in 17 (58.62%) after transoesophageal echocardiogram at 6 weeks. Over a mean of 1.75±1.0 years follow-up after LAAC, one patient had an AIS (incidence rate (IR) 1.97 per 100 patient-years). One patient with severe cerebral microangiopathy had a small ICH while on direct OAC and antiplatelet 647 days after LAAC.

Conclusions: LAAC in AIS-despite-OAC patients demonstrated a low annual AIS recurrence rate in our cohort (1.97%) compared with the expected IR based on their CHA₂DS₂-VASc scores (8.44%) and to recent large series of AIS-despite-OAC patients treated with OAC/aspirin only (5.3%-8.9%). These hypothesis-generating findings support randomised trials of LAAC in AIS-despite-OAC patients.

Keywords: Anticoagulants; Atrial Fibrillation; Embolism; Stroke.

Figure 1. Left atrial appendage closure in patients with atrial fibrillation and acute ischaemic stroke despite anticoagulation. AF, atrial fibrillation; AIS, acute ischaemic stroke; NVAF, non-valvular atrial fibrillation; RCT, randomised controlled trial; OAC, oral anticoagulant.

Figure 2. Recurrent ischaemic stroke risk in patients with AIS-despite-OAC was lower after LAAC compared with expected by CHA₂DS₂-VASc (A) and compared with data from previous publications on AIS-despite-OAC patients who were kept on OAC without LAAC as further described in table 3 (B). AIS, acute ischaemic stroke; OAC, oral anticoagulant; LAAC, left atrial appendage closure; CHA₂DS₂-VASc, Cardiac failure or dysfunction, Hypertension, Age ≥75 (Doubled), Diabetes, Stroke (Doubled)—Vascular disease, Age 65–74 and Sex category (Female)