Left Atrial Appendage Occlusion in Patients With Prior Intracranial Hemorrhage

Patients with atrial fibrillation (AF) and prior intracranial hemorrhage (ICH) have been excluded from clinical trials of left atrial appendage occlusion (LAAO). Because of clinician resistance to oral anticoagulation (OAC) for these patients, alternative stroke prevention methods are needed.

The aim of this study was to assess outcomes after LAAO in patients with prior ICH.

Patients enrolled in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry (LAAO Registry) from January 2016 to September 2021 with no history of ICH (Group 1) were compared vs those with prior ICH (Group 2). Primary outcomes were combined ischemic/undetermined stroke/transient ischemic attack and ICH.

Of 178,918 patients in the LAAO Registry, 133,947 met enrollment criteria (118,519 in Group 1 and 15,428 in Group 2). Group 1 had more cardiovascular comorbidities, whereas Group 2 had higher CHA₂DS₂-VASc and HAS-BLED scores. In-hospital as well as through a median 380-day follow-up, myocardial infarction and gastrointestinal bleeding were more common in Group 1, while neurologic complications occurred more often in Group 2; actual event rates were low. The non-neurologic bleeding in Group 1 was associated with greater use of OAC, while Group 2 had more device-related thrombosis. On multivariable analysis, the adjusted HRs of combined ischemic/undetermined stroke/transient ischemic attack (1.39; 95% CI: 1.25-1.54) and ICH (3.15; 95% CI: 2.69-3.68) were higher in Group 2.

Patients with prior ICH undergoing LAAO have increased neurologic complications. However, overall event rates are well below those associated with similar patients not receiving OAC. LAAO seems to be a reasonable option for patients with prior ICH.