Interventional occlusion of the left atrial appendage (LAA-O) is an established therapeutic option in atrial fibrillation (AF) patients, which are not suitable for oral anticoagulation (OAC) therapy, mainly due to previous bleeding events. Despite broad evidence is available that ischemic stroke can be effectively prevented by LAA occluder implantation, less is known about characteristics and rate of bleeding events after LAA occlusion under antiplatelet therapy (APT). Hence, we analysed bleeding events before and after LAA-O in patients with a history of OAC related bleeding.

Methods

Between 2015 and 2021 in 339 AF patients LAA-O was performed at University Medical Center Ulm. 228/339 patients with previous OAC related bleeding event and a follow-up > 6 months were identified, whereas 111/339 patients without OAC-related bleeding and/or incomplete follow-up were excluded from our study cohort. Most common preinterventional bleeding event in the study group was gastrointestinal (GI) bleeding (121/339 patients (53%)), followed by intracranial bleeding (ICB) 37/228 patients (16%)) and epistaxis (EPX; 22/228 patients (10%)). LAA occlusion was performed by different generations of Watchman or Amplatzer devices. In patients that were still on OAC, anticoagulation was discontinued 24 to 48 hours before scheduled implantation procedure. Patients were loaded with 500mg aspirine and 600mg clopidogrel for antiplatelet medication 4h before the procedure.

In 45/228 (19.3%) patients under APT further bleeding events after LAA occlusion was registered. Bleeding during follow-up occurred more often in patients on single APT (SAPT; 28/228 (12%), compared to 17/228 patients (7.4%; p<0.01) on dual ATP (DAPT). GI bleeding remained the most common type of bleeding under APT (26/228 patients; 11.4%), followed by EPX (11/45 (25%), whereas ICB occurred in a single patient (1/228; (0%) under APT after LAA occluder implantation.

Conclusion

Bleeding events after LAA occlusion were significantly reduced in AF patients with prior OAC related bleeding despite APT. Remarkably, bleeding occurred more often under SAPT compared to DAPT. Moreover, APT in patients with prior OAC related bleeding leads to tremendously reduced intracranial bleeding rate, whereas GI bleeding and EPX remained a clinical problem in patients after LAA occlusion.