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Published on: February 26, 2013
Percutaneous Left Atrial Appendage Closure in Patients With Cardioembolic Breakthrough Stroke: An International
Roberto Galea1,2, Gavino Casu3, Tommaso Bini1,4
1Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.
Insights
Left atrial appendage closure (LAAC) is safe for non-valvular atrial fibrillation (AF) patients with recurrent ischemic stroke. LAAC may offer additive protection beyond oral anticoagulation (OAC) for secondary stroke prevention.
Area of Science:
- Cardiology
- Neurology
- Medical Devices
Background:
- Patients with non-valvular atrial fibrillation (AF) experiencing ischemic stroke despite oral anticoagulation (OAC) have a high risk of recurrence (5.3%-8.9% annually).
- Optimal secondary prevention strategies for these high-risk patients remain undetermined.
Purpose of the Study:
- To evaluate the safety and efficacy of percutaneous left atrial appendage closure (LAAC) in AF patients who have experienced a cardioembolic ischemic stroke while on OAC.
- To assess the rate of recurrent ischemic stroke and procedure-related complications following LAAC in this patient cohort.
Main Methods:
- A review of prospectively collected data from four European centers on LAAC procedures in AF patients with ischemic stroke under OAC.
- Inclusion criteria required neurologist-confirmed cardioembolic stroke and adequate OAC at the time of the event.
- Primary endpoint was recurrent ischemic stroke at 2 years; secondary endpoints included complications and mortality.
Main Results:
- Of 2234 LAAC procedures, 95 involved patients with cardioembolic breakthrough strokes, with LAAC performed a mean of 4 months post-stroke.
- The majority of patients (83% at discharge, 79% at follow-up) remained on OAC.
- At a median follow-up of 713 days, 4% experienced recurrent ischemic stroke, with rare complications (1%) and 5% mortality.
Conclusions:
- Percutaneous left atrial appendage closure (LAAC) is a safe and feasible option for AF patients with cardioembolic breakthrough stroke.
- LAAC may provide additive protection against recurrent stroke compared to OAC alone, warranting further investigation.
- Results from ongoing randomized trials are necessary to confirm these findings.
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.
