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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Left Atrial Appendage Closure for Patients with Cerebral Amyloid Angiopathy and Atrial Fibrillation: the LAA-CAA
Matthew Schrag1, Brian Mac Grory2, Alex Nackenoff3
1Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA. matthew.schrag@vanderbilt.edu.
Insights
Left atrial appendage closure (LAAC) is a safe option for patients with cerebral amyloid angiopathy (CAA) and atrial fibrillation (AF), reducing stroke risk without long-term anticoagulation.
Area of Science:
- Cardiology
- Neurology
- Medical Devices
Background:
- Anticoagulation increases intracerebral hemorrhage (ICH) risk in cerebral amyloid angiopathy (CAA) patients.
- Managing stroke risk in patients with both atrial fibrillation (AF) and CAA is challenging due to bleeding risks.
- Left atrial appendage closure (LAAC) offers an alternative to oral anticoagulation (OAC) for stroke risk reduction.
Purpose of the Study:
- To evaluate the safety and tolerability of LAAC in patients with severe CAA and AF.
- To assess stroke and hemorrhage rates following LAAC in this high-risk population.
Main Methods:
- Observational cohort study of 26 patients with severe CAA and AF undergoing LAAC (Watchman™, Amulet®, Lariat, or surgical closure).
- Patients received short-term antiplatelet or anticoagulation therapy post-procedure.
- Aggressive blood pressure management and fall precautions were implemented.
Main Results:
- All LAAC procedures were tolerated.
- No ischemic strokes or symptomatic ICH occurred within 30 days post-implantation.
- One patient experienced an ischemic stroke during long-term follow-up (average 25 months); no other thromboembolic events were noted.
Conclusions:
- LAAC appears to be a safe and tolerable treatment for reducing stroke risk in patients with CAA and AF.
- LAAC may serve as a viable alternative to OAC in this patient group.
- Further research with larger cohorts and longer follow-up is needed to confirm efficacy for stroke and ICH prevention.
Abstract:
Anticoagulation increases the risk of intracerebral hemorrhage (ICH) in patients with cerebral amyloid angiopathy (CAA), so the management of stroke-risk in patients with both atrial fibrillation (AF) and CAA is controversial. Advances in left atrial appendage closure (LAAC) techniques provide a stroke-risk-reduction option which avoids long-term oral anticoagulation (OAC). We aimed to evaluate the safety of this intervention in patients with CAA. This is an observational cohort study of patients with severe CAA (with or without ICH) and AF who were treated with LAA closure. The Watchman™ and Amulet® LAAC devices and Lariat procedure or open surgical closure of the LAA were all considered acceptable means of closure. Patients with symptomatic ICH and those naïve to anticoagulation were placed on clopidogrel and/or aspirin for 6 weeks after the procedure; patients who previously tolerated anticoagulation remained on warfarin or a DOAC for 6 weeks post-procedure. All anticoagulation therapy was discontinued after confirmation of LAAC. All patients had aggressively optimized blood pressure and fall precautions in addition to surgical intervention. Safety, tolerability, stroke, and hemorrhage rates were documented. Twenty-six patients with a mean CHA2DS2-VASc score of 4.6 were treated, 13 with a history of symptomatic lobar hemorrhage and 13 without. All patients who completed LAAC tolerated the device implantation. There were no documented ischemic strokes or symptomatic ICH during the 30 days after device implantation. Patients were followed for an average of 25 months. One patient who underwent Lariat LAAC had an ischemic stroke in follow-up, but recovered well; there were no other thromboemboli in this cohort. This cohort study provides evidence that LAAC appears to be a safe and tolerable treatment to reduce stroke risk in patients with CAA. Because of the small size of the cohort and relatively short follow-up, the efficacy for stroke and ICH prevention is not conclusive, but the preliminary results are encouraging. LAA closure may be a good alternative to anticoagulation in patients with CAA and atrial fibrillation.
