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

AF Management in a Patient Intolerant to Oral Anticoagulation Therapy

October 2014

Oral anticoagulation is the gold standard therapy to prevent thromboembolic events in patients with atrial fibrillation (AF). However, up to 44% of patients are reported to have relative or absolute contraindications to chronic warfarin therapy. 1, 2, 3

The left atrial appendage (LAA) is a pouch located in the antero-lateral aspect of the left atrium (Figure 1). The LAA is known to be a major source of thromboemboli in the heart.4 Recently, a minimally invasive percutaneous approach using an epicardial suture for ligation of the LAA was approved by the FDA (the LARIAT™ procedure). The University of Minnesota Heart Care team is one of the pioneering programs in the country utilizing the technique. Here, we describe the case of an elderly gentleman with atrial fibrillation in the setting of a complex cardiac history who was intolerant to oral anticoagulation therapy. He was successfully managed using the LARIAT™ procedure.

— Figure 1


A 75-year-old man with a clinical history significant for AF, hypertension, hyperlipidemia, and previous episodes of transient ischemic attacks (TIA) was referred to the program. He had previously been placed on oral anticoagulation therapy to minimize stroke risk; however, he developed an intra-cranial bleed on treatment, and anticoagulation therapy was halted.


A chest computed tomography scan was performed to evaluate the patient’s LAA anatomy, which was found to have an acceptable size and shape for the LARIAT™ procedure. Under general anesthesia and fluoroscopy guidance, the epicardial space was accessed through a subxiphoid approach. To assure accurate placement of the suture around the LAA, the left atrium was accessed through a transseptal puncture. Through a sheath placed in the left atrium, a magnet-tipped guidewire was advanced into the LAA, while another magnet-tipped guidewire was advanced through the epicardial space. After connecting the tips of both guidewires (Figure 2), a LARIAT™ Suture Delivery Device was advanced over the epicardial guide wire and the snare was placed over the LAA. Total occlusion was confirmed by fluoroscopy and echocardiogram monitoring. The patient recovered well after the procedure and was discharged home a few days later.

— Figure 2


Novel, non-pharmacologic approaches to stroke risk reduction in AF are valuable for those patients with contraindications to oral anticoagulation therapy. The aim of these approaches is total occlusion of the LAA. However, skill of the practitioner is key to optimum patient outcomes, as the LAA can be easily damaged, leading to increased postoperative bleeding. Furthermore, an unsuccessful occlusion can result in a patent flow or a residual stump in the pouch of the LAA, with an increased risk of late thromboembolic events.5

Case study presented by: Luciano Amado, MD, FACC
University of Minnesota Heart Care
Fairview Southdale Hospital


1. Amin A. Oral anticoagulation to reduce risk of stroke in patients with atrial fibrillation: current and future therapies. Clin Interv Aging. 2013;8:75-84.

2. Singh IM, Holmes D. Left atrial appendage closure. Curr Cardiol Rep. 2010;12:413-21.

3. Cruz-Gonzalez I, Yan BP, Lam YY. Left atrial appendage exclusion: state-of-the-art. Catheter Cardiovasc Interv. 2010;75:806-13.

4. Johnson WD, Ganjoo AK, Stone CD, Srivyas RC, Howard M. The left atrial appendage: our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg. 2000;17(6):718-22.

5. Apostolakis E, Papakonstantinou NA, Baikoussis NG, Koniari I, Papadopoulos G. Surgical strategies and devices for surgical exclusion of the left atrial appendage: a word of caution. J Card Surg. 2013;28(2): 199-206.

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