Left atrial appendage closure (WATCHMAN™) after bleeding complications during oral anticoagulant therapy in high risk patients

Abstract

a b s t r a c tIntroduction: Therapy with coumarin-derivates in patients with atrial fibrillation is often associated with a high risk of bleeding complications. The LAA-closure with the WATCHMAN™ device provides an alternative to lifetime anticoagulation. We evaluated success rate and safety of WATCHMAN™ implantation in patients with atrial fibrillation and contraindications to oral anticoagulation due to severe bleeding. Methods: In 26 patients (72 ± 11 years, 8 female) with contraindications to anticoagulation due to severe bleeding (19 patients with gastrointestinal bleeding and 7 patients with hemorrhagic strokes) we performed LAA-closure with the WATCHMAN™ device. After LAA-closure patients received a short time dual antiplatelet therapy with aspirin and clopidogrel (100 mg of aspirin and 75 mg clopidogrel per day) for 6 weeks, followed by a monotherapy with 100 mg of aspirin per day. We screened patients for ischemic or bleeding events and performed a transoesophageal echocardiography at 6 weeks, 6 and 12 months after the implantation of the WATCHMAN™ device. Results: WATCHMAN™ device was positioned in a total of 25 patients (96%), 1 patient was excluded because of thrombus-detection in LAA. One pericardial effusion (4%) appeared after positioning and was successfully drained. In the follow-up at 6 weeks, 6 and 12 months 2 patients (8%) presented a severe bleeding event 8 weeks and 9 months after LAAclosure (1 patient with a bleeding of oesophageous varices, 1 patient with a bleeding of the hemorhoides). None of the patients got either an ischemic or hemorrhagic stroke or a systemic embolism. Transoesophageal echocardiography demonstrated a correct position of the device in each of the 25 patients, no device-attached thrombus or device embolization. Conclusion: The closure of the left atrial appendage with a WATCHMAN™ Device and a subsequent treatment with a short time dual antiplatelet therapy in high risk patients after bleeding complications due to oral anticoagulation with coumarin-derivates appears to be a save alternative treatment strategy to long-term oral anticoagulation.

Amplatzer Cardiac Plug for Stroke Prevention in Patients with Atrial Fibrillation and Bigger Left Atrial Appendix Size

“…During 12 months follow up they found none of the patients got either an ischemic or hemorrhagic stroke or a systemic embolism and no deviceattached thrombus. 21 Lack of data warrant clinical trial with sufficient sample size to have definite answer on whether direct dual antiplatelet or anticoagulant precedes dual antiplatelet as appropriate treatment after ACP implantation. However, lesson learnt from our subjects with bigger LAA size, anticoagulant preceding antiplatelet therapy seems more appropriate to prevent device-related thrombus and stroke event.…”