Left Atrial Appendage Closure in Patients with Atrial Fibrillation and Acute Ischemic Stroke Despite Anticoagulation

Background: The occurrence of acute ischemic stroke (AIS) while regularly using oral anticoagulants (OAC) is an increasingly recognized problem among nonvalvular atrial fibrillation (NVAF) patients. Due to the high risk of AIS recurrence (reported 5.3-8.9 per 100 patient-years) even when the type of OAC is changed, we aimed to elucidate the potential role of left atrial appendage closure (LAAC) for prevention of recurrent strokes among AIS-despite-OAC patients. Methods: Through retrospective review of electronic medical records of a single hospital system between January 2015 and October 2021, we collected baseline and follow-up data from consecutive NVAF patients who had AIS despite regular use of OAC per current guidelines and subsequently underwent endovascular LAAC for recurrent stroke prevention. The primary outcome measure was the occurrence of AIS after LAAC, and the safety outcome was symptomatic intracerebral hemorrhage (ICH). Results: Twenty-nine patients had the endovascular LAAC specifically because of AIS-despite-OAC. The mean age was 73.4 {+/-} 8.7, 13 were female (44.82%). Mean CHA2DS2-VASc score was 5.96 {+/-} 1.32, with an expected AIS risk of 8.44 per 100 patient-years. Fourteen of the patients had two or more past AIS-despite-OAC. After LAAC, 27 patients (93.10%) were discharged on anticoagulant which was discontinued in 17 (58.62%) after transesophageal echocardiogram (TEE) at 6 weeks. Over a mean of 1.75{+/-}1.0 years follow-up after LAAC, only one patient had an AIS (incidence rate [IR] 1.97 per 100 patient-years) and one patient had a small ICH (IR 1.97 per 100 patient-years). Conclusions: LAAC in patients who had AIS-despite-OAC demonstrated a low annual rate of recurrent AIS in our cohort (1.97%) compared both to the expected IR based on their CHA2DS2-VASc scores (8.44%) and to the recent large series of AIS-despite-OAC patients treated with OAC/aspirin only (5.3%-8.9%). These findings support randomized trials of LAAC in patients who have AIS-despite-OAC.