Percutaneous left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation and contraindication for anticoagulation.
BACKGROUND
Stroke, as the third cause of death in developed countries, is a public health issue. Atrial fibrillation is an important cause of ischemic stroke and its prevention is efficient with oral anticoagulation. However, oral anticoagulation can be contraindicated because of hemorrhagic risk related to these treatments. Percutaneous left atrial appendage occlusion is a new alternative of oral anticoagulation for patients with atrial fibrillation and high risk of cardio-embolic stroke but contraindicated for oral anticoagulation.


METHODS
We describe in this paper the procedure of left atrial appendage occlusion with the Amplatzer cardiac plug device, used in our center in Grenoble university hospital, for the first three patients who have been treated with this device. These three patients (one man and two women) have all atrial fibrillation with neurological complication of this arrhythmia, as ischemic stroke. Oral anticoagulation is indicated to prevent another ischemic stroke. However, they all have a high risk of cerebral bleeding for different reasons (cavernomatosis, history of intracerebral hemorrhage and aneurysm of the polygon of Willis). Consequently, they have a high risk of cardio-embolic complication but contraindication for oral anticoagulation. They have been treated by left atrial appendage occlusion with Amplatzer cardiac plug device by percutaneous and trans-septal access. Then, they have been followed by neurologist and cardiologist, with clinical and paraclinical evaluation by echocardiography.


RESULTS
Our three first patients have been successfully implanted, without periprocedural complication. No latest adverse event was observed, and particularly no cardiac or neurologic adverse event.


CONCLUSIONS
The technique of left atrial appendage occlusion is a very interesting and promising technique for ischemic stroke prevention in patient with high risk of cardio-embolic complication because of atrial fibrillation, but high risk of bleeding and contraindication for oral anticoagulation. Because of frequency of both atrial fibrillation and contraindication for oral anticoagulation, occlusion of the left atrial appendage should become an interesting alternative for many patients. However, it remains an invasive procedure and efficacy and indications need to be evaluated in further clinical trials. Risk/benefit ratio must be carefully assessed and compared to that of the new anticoagulant drugs.
Stroke unit, neurology, university hospital, boulevard de la Chantourne, 38043 Grenoble cedex 9, France. Electronic address: deborah.grossetjanin@gmail.com.
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Grosset-Janin
Cardiology, university hospital, boulevard de la Chantourne, 38043 Grenoble cedex 9, France.
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Barth
Cardiology, university hospital, boulevard de la Chantourne, 38043 Grenoble cedex 9, France.
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Bertrand
Stroke unit, neurology, university hospital, boulevard de la Chantourne, 38043 Grenoble cedex 9, France; Inserm U 836 UJF-CEA, team 5, Grenoble institut neurosciences, université Joseph-Fourier, site santé, bâtiment Edmond-J.-Safra, chemin Fortuné-Ferrini, 38706 La Tronche cedex, France.
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Detante
D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D020517:Atrial Appendage / Q000601:surgery*; D001281:Atrial Fibrillation / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D002545:Brain Ischemia / Q000209:etiology / Q000517:prevention & control; D006348:Cardiac Surgical Procedures; D000075202:Contraindications; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D020300:Intracranial Hemorrhages / Q000453:epidemiology; D008279:Magnetic Resonance Imaging; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D009422:Nervous System Diseases / Q000209:etiology; D012306:Risk; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
D000925:Anticoagulants
Atrial fibrillation; Fibrillation atriale; Infarctus cérébral; Left atrial appendage; Occlusion de l’auricule gauche; Stroke