Ischaemic stroke prevention in patients with atrial fibrillation and high bleeding risk: opportunities and challenges for percutaneous left atrial appendage occlusion

Abstract

Patients with atrial fibrillation (AF) are at an increased risk of ischaemic stroke. The efficacy of stroke prevention with vitamin K antagonists in these patients has been well established. However, associated bleeding risks may offset the therapeutic benefits in patients with risk factors for bleeding. Despite improvements achieved by novel oral anticoagulants, bleeding remains a clinically relevant problem, especially gastrointestinal bleeding. Percutaneous occlusion of the left atrial appendage (LAA) may be considered as an alternative stroke prevention therapy in AF patients with a high bleeding risk. This paper explores patient groups in whom oral anticoagulation may be challenging and percutaneous LAA occlusion (LAAO) has a potentially better risk-benefit balance. The current status of LAAO and future directions are reviewed, and particular challenges for LAA occlusion requiring further clinical data are discussed. This article is a summary of the Third Global Summit on LAA occlusion, 15 March 2013, Barcelona, Spain.

Antithrombotic Therapy for Atrial Fibrillation

“…LAA Occlusion in ICH Survivors: Randomized trials indicate that LAA occlusion (LAAO) has similar efficacy to oral anticoagulation in patients with AF; thus, in ICH survivors with AF and high ischemic stroke risk, LAAO chestjournal.org is a potentially attractive option to reduce ischemic stroke and systemic embolism from AF without the need to expose patients to a long-term risk of oral anticoagulation. 345 Observational data from 1,025 patients suggest that LAAO might be safe and effective in patients with a contraindication to long-term oral anticoagulation, but only a minority of patients (15%) in this study had suffered ICH. 346 Small studies of ICH survivors suggest that LAAO, using antiplatelet treatment as periprocedural antithrombotic treatment, is safe and effective in this population, including those with CAA.…”

Left Atrial Appendage Closure as an Alternative to Warfarin for Stroke Prevention in Atrial Fibrillation

“…L eft atrial appendage closure (LAAC) has been investigated intensely for stroke prevention as an alternative to systemic oral anticoagulation in selected patients with high-risk nonvalvular atrial fibrillation (NVAF) (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). The PROTECT AF (Prospective Randomized Evaluation of the Watchman LAA Closure Device In Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy) trial was a multicenter, randomized controlled trial in NVAF patients comparing the Watchman device to warfarin for a composite primary endpoint of stroke, systemic embolism, and cardiovascular (CV) death (1,9).…”

Innovative Technologies in Cardiology: From Surprise to Habit or Forgetfulness

“…Эффективность окклюзии ушка левого предсердия (ОУЛП) с целью профилактики инсульта в качестве аль-тернативы приему антикоагулянтов у отдельных пациентов с ФП неклапанной природы (ФПНП), у которых имеется высоких риск развития тромбоэмболий, интенсивно изучалась [2][3][4][5][6][7][8][9][10][11][12]. В ходе выполнения многоцентрового РКИ PROTECT AF (Prospective Randomized Evaluation of the Watchman LAA Closure Device In Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy), включавшего больных с ФПНП, сравнивали эффективность имплан-тации устройства Watchman с применением варфарина по влиянию на основной комбинированный показатель частоты развития инсульта, эмболии в сосуды большо-го круга кровообращения (ЭСБКК) и смертности от осложнений сердечно-сосудистых заболеваний (ССЗ) [2,10].…”