Background and Purpose: Left atrial appendage occlusion (LAAO) is an accepted therapeutic option for stroke prevention; however, the ideal technique and device have not yet been identified. In this study we evaluate the potential role of a heart team approach for patients contraindicated for oral anticoagulants and indicated for left atrial appendage closure, to minimize risk and optimize benefit in a patient-centered decision-making process. Methods: Forty patients were evaluated by the heart team for appendage occlusion. Variables considered were CHA₂DS₂VASc, HASBLED, documented blood transfusions, comorbidities, event forcing anticoagulant interruption, past medical history, anatomy of the left atrial appendage, and patient quality of life. Twenty patients had their appendage occluded percutaneously (65% male, mean age 72.3 ± 7.5, mean CHA₂DS₂VASc 4.2 ± 1.5, mean HASBLED 3.5 ± 1.1). The other twenty underwent thoracoscopic occlusion (65% male, mean age of 74.9 ± 8, mean CHA₂DS₂VASc 6.0 ± 1.5, HASBLED mean 5.4 ± 1.4). Percutaneous patients were on dual antiplatelet therapy for the first three months and aspirin thereafter, whereas the others received no anticoagulant/antiplatelet therapy from the day of surgery. Follow up included TEE, CT scan, and periodical clinical evaluation. Results: Mean duration of procedures and hospital stay were comparable. All patients had complete exclusion of the appendage; at a mean follow up of 33.1 ± 14.1 months, no neurological or hemorrhagic events were reported. Conclusions: A heart team approach may improve the decision-making process for stroke and hemorrhage prevention, where LAAO is a therapeutic option. Percutaneous and thoracoscopic appendage occlusion seem to be comparably safe and effective. An epicardial LAAO could be advisable in patients for whom the risk of bleeding is estimated as being too high for post-procedural antiplatelet therapy.

Background: Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. Methods: Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA₂DS₂VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. Results: Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. Conclusion: Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.

Background: Gastrointestinal bleeding in patients with atrial fibrillation is an indication for left appendage occlusion. All endovascular devices mandate antithrombotic therapies: rebleeding risk remains an issue. To date, there are no reports on gastrointestinal rebleeding and stroke prevention by left appendage occlusion without any antithrombotic therapy in this category of patients. Methods: A total of 129 patients (male 85, mean age 76.6 ± 7.1, CHA₂DS₂Vasc 3.8 ± 1.5, HASBLED 3.3 ± 1.0; upper GI bleeding 10%, lower GI bleeding 86%, obscure occult 4.6%, on NOACS full dose 77.5%, NOACs reduced dose 13.1%, on anti-vitamin K 9.3%) with atrial fibrillation and history of repetitive gastrointestinal bleeding from ten centers underwent standalone thoracoscopic epicardial appendage closure without antithrombotic therapy for the entire follow up. Results: The observed bleeding rate was 0.91 events per year, equivalent to a relative risk of RR = 0.17 (p = 0.02) and a relative risk reduction (RRR) of 83%. The observed relative risk of stroke was 0.91 events per year, with a relative risk of RR = 0.19 (p = 0.03) and a relative risk reduction (RRR) of 81%. Conclusion: Standalone epicardial appendage occlusion without antithrombotic therapy in patients with repetitive gastrointestinal bleeding is safe and promising when rebleeding and stroke risk reduction need to be optimized.

Left atrial appendage therapies: a new topic for the Heart Team