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Observational Study
. 2025 Sep;32(9):e70365.
doi: 10.1111/ene.70365.

Percutaneous Left Atrial Appendage Closure in Patients With Cardioembolic Breakthrough Stroke: An International Observational Study

Roberto Galea  1   2 , Gavino Casu  3 , Tommaso Bini  1   4 , Angelo Laconi  3 , Pier Luigi Merella  3 , Konstantina Chalkou  5 , Alberto Preda  6 , Marco Cerciello  7 , Giuseppe D'Angelo  7 , Paolo Della Bella  7 , Patrizio Mazzone  6 , Elias Auer  4   8 , Antanas Gasys  1 , David Julian Seiffge  8 , Urs Fischer  8 , Lorenz Räber  1
Affiliations
Observational Study

Percutaneous Left Atrial Appendage Closure in Patients With Cardioembolic Breakthrough Stroke: An International Observational Study

Roberto Galea et al. Eur J Neurol. 2025 Sep.

Abstract

Background: Patients with non-valvular atrial fibrillation (AF) who experience an ischemic stroke despite oral anticoagulation (OAC) are at particularly high risk of recurrence, with a reported annualized ischemic stroke rate of 5.3%-8.9%. The optimal strategy for secondary prevention in these patients remains unknown.

Methods: We reviewed all percutaneous left atrial appendage closures (LAAC) attempted in AF patients experiencing an ischemic stroke under OAC and who were prospectively collected in four European centers. All index strokes were categorized by an experienced neurologist to exclude patients with non-cardioembolic etiology or insufficient OAC. The primary endpoint was a recurrent ischemic stroke at 2 years after the procedure. Secondary endpoints included procedure-related complications and 2-year death.

Results: Of 2234 patients submitted to LAAC procedure, 95 had a cardioembolic breakthrough stroke. LAAC procedures were performed at a mean of 4 months after the breakthrough stroke. The main antithrombotic therapy at discharge (83%) and at the latest follow-up (79%) consisted of OAC. At the median follow-up of 713 days, the primary endpoint occurred in 4 patients (4%). Procedure-related complications were rare (1%) whereas death occurred in 5% of patients.

Conclusion: LAAC procedures were safe and feasible in patients with cardioembolic breakthrough stroke. Recurrent stroke rates were lower than those reported in previous studies with OAC continuation after breakthrough stroke, suggesting a potential additive protection by LAAC on top of OAC. Results from ongoing randomized trials are required to validate our findings.

Keywords: atrial fibrillation; breakthrough stroke; left atrial appendage closure; oral anticoagulation; stroke.

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Conflict of interest statement

R.G. is a proctor and consultant for Abbott and reports speaking honorarium from Boston Scientific and research grants from Swiss Heart Foundation. E.A. reports research funding from the Gottfried & Julia Bangerter Rhyner foundation. U.F. reports research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, from Medtronic (BEYOND SWIFT, SWIFT DIRECT) and from Stryker, Rapid medical, Penumbra, Medtronic and Phenox (DISTAL), Boehringer Ingelheim (TECNO). Support of the Horton Foundation for the DO IT trial. Consultancies for Medtronic (fees paid to institution). Participation in an advisory board for AstraZeneca (former Alexion/Portola), Bayer, Boehringer Ingelheim, Biogen, AbbVie, Siemens (fees paid to institution). Member of a clinical event committee (CEC) of the COATING study (Phenox). Member of the data and safety monitoring committee (DSMB) of the TITAN, LATE_MT, IN EXTREMIS and RapidPulse trials. L.R. reports research grants to institution by Abbott‐Vascular, Boston‐Scientific, Biotronik, Heartflow, Sanofi, Regeneron. He reports speaker/consultation fees by Abbott‐Vascular, Amgen, AstraZeneca, CSL‐Behring, Canon, Occlutech, Sanofi, Vifor. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

FIGURE 1
FIGURE 1
Cumulative incidence function curve of ischemic stroke (A) and cerebrovascular events (B) at 2 years after LAAC. Central illustration. Main study results. LAAC, left atrial appendage closure; OAC, oral anticoagulation; TIA, transient ischemic attack.
See this image and copyright information in PMC

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