A New Strategy for Transcatheter Left Atrial Appendage Closure With Cerebral Embolic Protection in Patient With Left Auricular Thrombosis and Total Contraindication to Long-Term Anticoagulation

J INVASIVE CARDIOL 2017;29(3):E37-E38.

Key words: cerebral embolic protection, transcatheter LAA closure

Atrial fibrillation (AF) is the most common cardiac arrhythmia, occurring in 1%-2% of the general population. An important aspect is the treatment of AF in terms of stroke prevention. In patients with absolute contraindication to long-term anticoagulation due to high bleeding risk, left atrial appendage (LAA) closure is a valuable alternative. Unfortunately, thrombus in the LAA is a contraindication to the procedure because of high risk of embolization. We describe a clinical case with permanent AF, absolute contraindication to long-term anticoagulation therapy, and persistent thrombus formation in the LAA treated with transcatheter LAA closure and cerebral protection of the supraaortic trunks in order to avoid the risk of periprocedural stroke.

A 78-year-old male who was on warfarin presented with history of arterial hypertension, diabetes mellitus, remote spontaneous hemorrhagic pericardial effusion, permanent AF, and a previous hemorrhagic gastritis. He was transferred after a recent subdural hematoma under dabigatran to perform transesophageal echocardiography for the purpose of evaluating the feasibility of transcatheter LAA closure. Unfortunately, echocardiogram showed the presence of thrombus formation in the LAA. Anticoagulation with low-molecular-weight heparin and aspirin was resumed, but thrombus persisted in LAA at 1 month with ultrasound follow-up (Figure 1). After multidisciplinary discussion with a cardiac surgeon, neurologist, and interventionalist, we performed transcatheter LAA closure with TriGuard HDH embolic cerebral protection device (Keystone Heart, Ltd) (Figure 2).  Then, the cerebral protection system was removed and angiographic control of the renal and mesenteric arteries was performed to exclude distal embolization. We didn’t perform angiography of the supraaortic trunks because of the lack of any neurological dysfunction. LAA closure is a valuable alternative in patients with absolute contraindication to long-term anticoagulation due to high bleeding risk. Although the presence of thrombus in the LAA is a prohibitive condition to the invasive procedure, the cerebral distal protection device allowed to safely conduct transcatheter LAA closure, reducing the risk of cerebral embolization linked to periprocedural thrombus mobilization or manipulation. The patient was discharged with dual-antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg daily) for 1 month.  

From the Division of Cardiology, Ospedale Civile, Mirano, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted August 29, 2016, provisional acceptance given August 31, 2016,  final version accepted September 6, 2016. 

Address for correspondence: Jayme Ferro, MD, Cardiology Department, Mirano General Hospital, via Mariutto 13, Mirano, Venice, Italy. Email: jayme.ferro@gmail.com