Introduction: Percutaneous left atrial appendage occlusion (LAAO) has been shown to be non-inferior to warfarin in preventing strokes in patients with AF. However, relative contra-indication to anticoagulation or embolic strokes despite therapeutic anticoagulant remain the most common indications. There is also limited data to suggest that maintaining sinus rhythm by AF ablation could reduce the long term risk of stroke, but long-term anticoagulation is still recommended. Combining AF ablation with LAAO enables both symptom control and synergistic stroke reduction.
Methods: Patients undergoing combined LAAO + PVI procedure or LAAO alone between 2011 – 2021 at Imperial College Healthcare were reviewed. Post procedural anticoagulation plan was decided on a case by case basis at an MDT with multi-speciality input. All patients were assessed in outpatient clinic on an annual basis. Here
data was collected regarding recurrence of atrial arrythmias, significantbleeding events and embolic ischaemic events.
Results: 72 patients with AF and an indication for an LAAO device underwent either a combined LAAO implantation and PVI procedure (56 patients) or an LAAO alone (16 patients).
Procedural complications: The overall intra-procedural complication rate requiring intervention was 6.9%. This consisted of two groin complications, a retroperitoneal haematoma, a temporary phrenic nerve palsy and a pericardial effusion. Post-procedurally there were three significant bleeding events in the 30 day follow up period with patients a DOAC/antiplatelet respectively.
Post-procedural anticoagulation and device thrombosis: Due to intrinsic bleeding risks a significant proportion of patients were unable to take any form of post procedural anticoagulation to prevent device thrombosis following LAAO insertion; 51.7% of patients were either on no anticoagulation (21%) or single antiplatelet therapy (31%). On the TOE checks only one patient was found to have thrombus on their device.
Long-term outcomes: In the 56 patients that underwent the combined procedure they were followed for an average of 1.81 +/- 1.6 years and 53.6% of patients remain in sinus rhythm. Amongst the whole patient cohort (72 patients) they were followed up for an average of 2.65 years. The expected ischaemic stroke rate was 7.63 strokes and our observed stroke rate was 1.
Discussion: This is the first data to show the relative safety of no post-procedural anti-platelet or anticoagulant (51.7%) in those who have undergone a PVI + LAAO procedure. Patients who cannot take post procedural anti-platelets are often deemed unsuitable for this device which can be counterintuitive as it is their bleeding risk that derives them most benefit from this procedure. We have shown it may be safe to be on no anti-thrombotic agents post LAAO and AF ablation.
