Abstract
Background
Atrial fibrillation (AF) affects 1%-2% of the general population and 13% of individuals
older than 80 years of age. Anticoagulation has been the mainstay therapy to reduce
stroke risk. Patients with previous intracranial hemorrhage (ICH) or intraocular hemorrhage
(IOH) are at increased risk of recurrence if anticoagulation is continued or initiated.
Left atrial appendage (LAA) closure may obviate the need for long-term anticoagulation
in these patients.
Methods
We report our consecutive series of patients with nonvalvular AF with previous ICH
or IOH who underwent LAA closure with the AMPLATZER Cardiac Plug (ACP; St Jude Medical,
St Paul, MN), AMPLATZER Amulet, or WATCHMAN (Boston Scientific, Natick, MA) device.
Demographics, clinical status, procedural outcomes, and complications were collected
at baseline, during the procedure, at 3 months, at 1 year, and annually thereafter.
Results
Twenty-six patients with previous ICH (n = 24) or IOH (n = 2) underwent LAA closure
(9 with the ACP, 3 with the Amulet, and 7 with the WATCHMAN). The mean age was 76
± 7 years, and 61.5% were men with a mean CHADS2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) score of 3.2 ± 1.4 and CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age [≥ 75 years], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female] score) of 4.9 ± 1.7. No procedure-related complications occurred. Mean follow-up was
11.9 ± 13.3 months. One patient died at 13 months (this death was not related to the
procedure), and 1 patient had a transient ischemic attack at 20.6 months after the
procedure. No ischemic stroke, haemorrhagic stroke, or bleeding problems occurred
during follow-up.
Conclusions
In our consecutive series, LAA closure was found to be safe and effective in patients
with AF and a history of ICH or IOH.
Résumé
Introduction
La fibrillation auriculaire (FA) touche 1 % à 2 % de la population générale et 13
% des individus âgés de plus de 80 ans. L’anticoagulation a été le principal traitement
utilisé pour réduire le risque d’accident vasculaire cérébral (AVC). Les patients
ayant déjà souffert d’une hémorragie intracrânienne (HIC) ou d’une hémorragie intraoculaire
(HIO) sont exposés à un risque plus élevé de récidive si l’anticoagulation est poursuivie
ou amorcée. La fermeture de l’appendice auriculaire gauche (AAG) peut éviter de recourir
à l’anticoagulation chez ces patients.
Méthodes
Nous présentons nos séries consécutives de patients souffrant de FA non valvulaire
qui ont déjà eu une HIC ou une HIO et qui ont subi la fermeture de l’AAG à l’aide
du dispositif AMPLATZER Cardiac Plug (ACP; St Jude Medical, St Paul, MN), du dispositif
AMPLATZER Amulet ou du dispositif WATCHMAN (Boston Scientific, Marlborough, MA). Les
caractéristiques sociodémographiques, l’état clinique, les résultats interventionnels
et les complications étaient recueillis au début, durant l’intervention, à 3 mois,
à 1 an et annuellement par la suite.
Résultats
Vingt-six patients ayant déjà eu une HIC (n = 24) ou une HIO (n = 2) ont subi la fermeture
de l’AAG (9 à l’aide de l’ACP, 3 à l’aide de l’Amulet et 7 à l’aide du WATCHMAN).
L’âge moyen était de 76 ± 7 ans, et 61,5 % étaient des hommes ayant un score CHADS2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack, soit l’insuffisance cardiaque congestive, l’hypertension,
l’âge, le diabète, l’AVC/l’ischémie cérébrale transitoire [ICT]) moyen de 3,2 ± 1,4
et un score CHA2DS2VASc (Congestive Heart Failure, Hypertension, Age [≥ 75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female], soit l’insuffisance cardiaque congestive, l’hypertension, l’âge, le diabète,
l’AVC/l’ICT, la maladie vasculaire, l’âge [65 à 74 ans], le sexe [féminin]) moyen
de 4,9 ± 1,7. Aucune complication liée à l’intervention n’est apparue. Le suivi moyen
était de 11,9 ± 13,3 mois. Un patient est mort après 13 mois (ce décès n’était pas
lié à l’intervention) et 1 patient a subi une ICT 20,6 mois après l’intervention.
Aucun AVC ischémique, aucun AVC hémorragique ou problème hémorragique ne sont apparus
au cours du suivi.
Conclusions
Dans nos séries consécutives, la fermeture de l’AAG s’était avérée sûre et efficace
chez les patients souffrant de FA et ayant des antécédents de HIC ou de HIO.
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References
- Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study.JAMA. 2001; 285: 2370-2375
- Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications.Arch Intern Med. 1995; 155: 469-473
- Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation.Circulation. 2007; 115: 2689-2696
- Long-term prognosis after recovery from primary intracerebral hemorrhage.Neurology. 2002; 59: 205-209
- Recurrent primary intracerebral hemorrhage: a hospital based study.Acta Neurol Taiwan. 2007; 16: 74-80
- Recurrent primary cerebral hemorrhage: frequency, mechanisms, and prognosis.Stroke. 1998; 29: 1802-1805
- The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation) trial.Am Heart J. 2006; 151: 956-961
- Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry.Circulation. 2011; 123: 417-424
- ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association.Eur Heart J. 2012; 33: 2719-2747
- Canadian Cardiovascular Society Atrial Fibrillation Guidelines Committee. Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control.Can J Cardiol. 2012; 28: 125-136
- Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence.Circulation. 2006; 114: 119-125
- Percutaneous left atrial appendage closure: procedural techniques and outcomes.JACC Cardiovasc Interv. 2014; 7: 1205-1220
- Cardiac CT angiography for device surveillance after endovascular left atrial appendage closure.Eur Heart J Cardiovasc Imaging. 2015; 16: 1198-1206
- Recurrent brain hemorrhage is more frequent than ischemic stroke after intracranial hemorrhage.Neurology. 2001; 56: 773-777
- PROTECT AF Investigators. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial.Lancet. 2009; 374: 534-542
- PROTECT AF Investigators. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) trial.Circulation. 2013; 127: 720-729
- Long term results of the PROTECT AF: the mortality effects of left atrial appendage closure versus warfarin for stroke prophylaxis in AF. Paper presented at: Heart Rhythm Society Scientific Session.May 8-11, 2013 (Denver, CO)
- 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; 64: 1-12
- Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis.J Am Coll Cardiol. 2015; 65: 2614-2623
Tzikas A, Shakir S, Gafoor S, et al. Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug [e-pub ahead of print]. EuroIntervention http://dx.doi.org/10.4244/EIJY15M01_06, accessed January 4, 2016.
- Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology).J Am Coll Cardiol. 2013; 61: 2551-2556
- Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial.Lancet. 2006; 367: 1903-1912
- Percutaneous left atrial appendage closure with the AMPLATZER cardiac plug device in patients with nonvalvular atrial fibrillation and contraindications to anticoagulation therapy.J Am Coll Cardiol. 2013; 62: 96-102
- Dabigatran versus warfarin in patients with atrial fibrillation.N Engl J Med. 2009; 361: 1139-1151
- Apixaban versus warfarin in patients with atrial fibrillation.N Engl J Med. 2011; 365: 981-992
- Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.N Engl J Med. 2011; 365: 883-891
- Left atrial appendage occlusion in atrial fibrillation after intracranial hemorrhage.Neurology. 2014; 82: 135-138
Article info
Publication history
Published online: August 11, 2015
Accepted:
July 30,
2015
Received:
May 19,
2015
Footnotes
See editorial by Jaffer and Whitlock, pages 281-282 of this issue.
See page 353 for disclosure information.
Identification
Copyright
© 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
