Clinician-to-Clinician Update Clinician-to-Clinician Update

Risk of Stroke and Bleeding Addressed with Occlusion Device

August 2017

Contributed by Lin Yee Chen, MD, MS

Patients with nonvalvular atrial fibrillation (NVAF) are poor candidates for anticoagulant medication if they also have a high risk of bleeding due to frequent falls, gastrointestinal conditions, or prior stroke. For these patients who have a high CHA2DS2-VASc score—an instrument used to assess the risk of stroke in patients with atrial fibrillation—the Watchman left atrial appendage (LAA) occlusion device can be considered an appropriate alternative to anticoagulants.1, 2

Patient

An 83-year-old man with a history of NVAF was referred to M Health Atrial Fibrillation Center specialists at University of Minnesota Health Clinics and Surgery Center. He had undergone successful prior ablation for atrial tachycardia and was on anticoagulant medication for atrial fibrillation not related to valve disease. The patient, however, had begun to experience frequent falls with activity due to frailty with age. His physicians at the clinic were concerned that this risk, combined with his use of the anticoagulant warfarin to manage chronic NVAF, put him at high risk of cerebrovascular hemorrhage or bleeding from a fall.

Management

The patient’s history of heart problems combined with hypertension put his CHA2DS2-VASc score at 4, putting him at moderately high risk for cardioembolic stroke. He was considered a candidate for LAA occlusion with the Watchman device. Transesophageal echocardiography (TEE) indicated that the patient’s LAA anatomy was suitable for placement of the device, and the patient agreed to the procedure. At the clinic, an interventional cardiologist and a cardiac electrophysiologist, skilled respectively in complex catheterization techniques and analysis of cardiac rhythm, deployed a 21 millimeter Watchman device without complication. TEE showed that the device had optimal position and anchoring within the LAA and was appropriately compressed to ensure that the appendage had been completely sealed.

August-2017-Consult-Heart-Care-Case-Study-Craft
— Placement of Watchman device in the left atrial appendage. Image provided courtesy of Boston Scientific. ©2017 Boston Scientific Corporation or its affiliates. All rights reserved.

The patient was continued on warfarin and aspirin for 45 days to prevent clots as scar tissue formed over the LAA. An additional TEE confirmed that the device remained anchored in place with new scar tissue. He was allowed to stop taking warfarin but continues to take aspirin together with clopidogrel, another antiplatelet agent. At 6 months postprocedure, he can expect to discontinue clopidogrel and continue with aspirin.

Discussion

A history of frequent falls or significant bleeding while on anticoagulants should prompt an evaluation of continued use of warfarin for NVAF. LAA occlusion with the Watchman device can be considered as an alternative to warfarin for NVAF patients with a high stroke risk who also carry a high risk of bleeding from other conditions of advanced age.3

References

  1. Holmes DR, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014 Jul 8;64(1):1-12. doi: 10.1016/j. jacc.2014.04.029.
  2. Panikker S, Lord J, Jarman JW, et al. Outcomes and costs of left atrial appendage closure from randomized controlled trial and real-world experience relative to oral anticoagulation. Eur Heart J. 2016 Dec 7;37(46):3470-3482. doi: 10.1093/eurheartj/ehw048. Epub 2016 Mar 1.
  3. Price MJ, Reddy VY, Valderrabano M, et al. Bleeding outcomes after left atrial appendage closure compared with long-term warfarin. JACC Cardiovasc Interv. 2015;8(15):1925-1932.
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