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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was internally funded. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was performed with the approval of and in accordance with the guidelines of the institutional review board (IRB) of MGB Health System I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes * OAC : oral anticoagulants NVAF : non-valvular atrial fibrillation VKA : vitamin-K antagonists AIS : acute ischemic stroke DOAC : direct oral anticoagulant ICH : intracerebral hemorrhage LAAC : left atrial appendage closure AF : atrial fibrillation cSVD : cerebral small vessel disease TEE : transesophageal echocardiogram IR : incidence rate RCT : randomized control trial