Left atrial appendage occlusion as an alternative to anticoagulation in patients with atrial fibrillation

Rodríguez Villadeamigo, Gemma; Gómez Reyes, Jose Luis; Pedregal González, Miguel

doi:10.1016/j.medcle.2019.04.056

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However, they are not exempt from haemorrhagic risk due to their own anticoagulant effect, they have limitations for patients with kidney failure and may have side effects.<a class="elsevierStyleCrossRef" href="#bib0030">1</a>Several studies have shown that the main source of thrombi in patients with atrial fibrillation (AF) is the left atrial appendage (LAA), so its removal by surgical excision or by percutaneous techniques reduces the rate of thromboembolic events and allows to eliminate anticoagulant treatment.<a class="elsevierStyleCrossRefs" href="#bib0030">1,2</a>We report the case of an 84-year-old female, independent for the basic activities of daily living, with a history of: hypertension, paroxysmal AF, mild mitral and aortic regurgitation, dyslipidaemia, obesity, chronic anaemia and right hemicolectomy due to colorectal cancer. A year before, treatment with acenocoumarol was discontinued due to INR instability and epistaxis, and she was anticoagulated with enoxaparin. Currently on treatment with: bisoprolol 2.5mg/24h, simvastatin 20mg/24h, furosemide 40mg/24h and enoxaparin 60mg/24h.An assessment of her anticoagulation treatment was carried out by the cardiology department.During history-taking, she reported prolonged asthenia, an emergency department visit 2 months earlier due to palpitations (the last episode of AF reported) and frequent epistaxis during the previous month.The only finding on examination was a grade II/VI systolic murmur with preserved second heart sound. An electrocardiogram was performed in the cardiology clinic (sinus rhythm at 68bpm, preserved AV conduction, without intraventricular conduction or repolarization abnormalities) and several ancillary tests were requested and reviewed in a subsequent visit: the transthoracic echocardiography showed a slightly dilated left atrium with an area of 26cm2, an non-dilated left ventricle with preserved ejection fraction, normal right cavities, mild and degenerative aortic and mitral regurgitation, as well as moderate tricuspid regurgitation that allowed the assessment of mild pulmonary hypertension.Blood pressure Holter monitoring did not show any abnormalities and a laboratory test highlighted macrocytic hypochromic anaemia with haemoglobin levels of 7g/dl, creatinine clearance of 35ml/min and a ProBNP of 6796pg/ml; with the rest of values being normal.With all this, the following presumptive diagnosis was obtained: Paroxysmal AF, CHADVASC score: 4 (high thromboembolic risk), HAS-BLED: 5 (high risk of bleeding) and HEMORR2HAGES: 6 (high risk of bleeding), in a patient with moderate stage 3 kidney disease.Due to external bleeding, INR instability and borderline renal function for severity (independent risk factor for bleeding), it was appropriate to consider an alternative treatment, such as percutaneous occlusion of the LAA. Anticoagulated with apixaban 2.5mg/12h during the time the patient considered the interventional option.The patient was asked to return one month later and accepted the percutaneous procedure, requesting a transoesophageal ultrasound to measure ostium and LAA depth (with a view to deciding on the size of the device to be used). The procedure was performed without complications, implanting an Amplatzer® device, discontinuing apixaban and continuing with aspirin 100mg/24h.There are 4 scales of haemorrhagic risk.<a class="elsevierStyleCrossRef" href="#bib0040">3</a> The most popular is HAS-BLED, but HEMORR2HAGES is the only one that takes neoplastic disease into account as a bleeding risk factor. Some scale that recognizes neoplastic disease as a thromboembolic factor is missing in the management of these patients.Despite studies showing that percutaneous closure of LAA reduces the rate of thromboembolic events and allows the elimination of anticoagulant treatment,<a class="elsevierStyleCrossRefs" href="#bib0030">1,4,5</a> it seems that oral treatments are still the treatment of choice. Only the following cases would be candidates for atrial appendage occlusion: patients with nonvalvular AF with life expectancy ≥1 year, significant thromboembolic risk (CHADS≥2) and very high bleeding risk (HAS-BLED≥3) or an absolute contraindication for long-term anticoagulation.In conclusion, a percutaneous occlusion procedure was considered the most effective option, since on the one hand the treatment with VKA associated great INR instability and on the other hand the use of DOAC was compromised by borderline renal failure for severity and did not prevent frequent epistaxis." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rodríguez Villadeamigo G, Gómez Reyes JL, Pedregal González M. Cierre de orejuela izquierda como alternativa a la anticoagulación en la fibrilación auricular. Med Clin (Barc). 2020;155:88–89." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento no farmacológico de la fibrilación auricular. Ablación, cardioversión eléctrica, marcapasos y cierre de la orejuela" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Atienza" 1 => "A. 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A" "paginaInicial" => "25" "paginaFinal" => "32" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Selección de lo mejor del año 2017 en cierre percutáneo de la orejuela izquierda: completando la evidencia científica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Pérez de Prado" 1 => "A. Serrador" 2 => "P. Jiménez-Quevedo" 3 => "T. Benito González" 4 => "F. Fernández Vázquez" 5 => "M. Pan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.recesp.2017.10.016" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "2018" "volumen" => "71" "paginaInicial" => "225" "paginaFinal" => "227" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29352720" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF Trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "V.Y. Reddy" 1 => "S.K. Doshi" 2 => "S. Kar" 3 => "D.N. Gibson" 4 => "M.J. Price" 5 => "K. Huber" 6 => "PREVAIL and PROTECT AF Investigators" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2017.10.021" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2017" "volumen" => "70" "paginaInicial" => "2964" "paginaFinal" => "2975" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29103847" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015500000002/v1_202007190713/S2387020620302540/v1_202007190713/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015500000002/v1_202007190713/S2387020620302540/v1_202007190713/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620302540?idApp=UINPBA00004N"]

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Vol. 155. Issue 2.

Pages 88-89 (July 2020)

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