Left Atrial Appendage Occlusion in Patients with Non-Valvular Atrial Fibrillation and History of Intracranial Hemorrhage: A Review

Atrial Fibrillation (AF) is associated with an increased risk of thromboembolism due to formation of intracardiac thrombus mostly in left atrial appendage. Anticoagulant agents are used to reduce the risk of thromboembolism but have concerning bleeding side effect, making their use very challenging particularly in patients with high HAS-BLED risk score. WATCHMAN device (Boston Scientific, St. Paul, Minnesota) is a Left Atrial Appendage Occlusion (LAAO) device, which was tested in two major randomized trials. PROTECT AF (Percutaneous Left Atrial Appendage Closure for Stroke Prophylaxis in Patients with Atrial Fibrillation) trial, and PREVAIL (Prospective Randomized Evaluation of the WATCHMAN Left Atrial Appendage Closure Device in Patients with Atrial Fibrillation versus Long Term warfarin Therapy) trial, both evaluated WATCHMAN device’s safety and efficacy compared to warfarin. These trials showed WATCHMAN device to be noninferior to warfarin. However, patients with history of intracranial hemorrhage were excluded from these trials due to concern of increased recurrent bleeding in presence of perioperative use of anticoagulation. Purpose of this review is to evaluate existing evidence and share our experience of LAAO in this high-risk population.