ORIGINAL ARTICLE   

Minerva Cardiology and Angiology 2022 October;70(5):537-44

DOI: 10.23736/S2724-5683.20.05474-2

Copyright © 2020 EDIZIONI MINERVA MEDICA

language: English

Safety of reduced or absent antithrombotic therapy after left atrial appendage closure in patients affected by hereditary hemorrhagic telangiectasia and atrial fibrillation

Martino PEPE ¹, Patrizia SUPPRESSA ², Antonio F. GIULIANO ², Palma L. NESTOLA ¹ ✉, Alessandro S. BORTONE ³, Emanuela DE CILLIS ³, Tommaso ACQUAVIVA ³, Cinzia FORLEO ¹, Marco MOSCARELLI ⁴, Gennaro M. LENATO ², Carlo SABBÀ ²

¹ Division of Cardiology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy; ² C. Frugoni Internal Medicine Unit, Department of Interdisciplinary Medicine, Center for Rare Diseases, VascERN HHT Reference Center Policlinico University Hospital, University of Bari, Bari, Italy; ³ Division of Heart Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy; ⁴ Cardiothoracic and Vascular Department, Maria Cecilia Hospital GVM Care & Research, Cotignola, Ravenna, Italy

BACKGROUND: Left atrial appendage (LAA) closure represents a novel therapeutic chance for patients with contraindications to long-term anticoagulation therapy, such as those affected by hereditary hemorrhagic telangiectasia (HHT) and atrial fibrillation (AF). Nevertheless, current experts’ indications suggest the postprocedural administration of antithrombotic therapies to minimize the residual thromboembolic risk due to AF and to the need for device endothelialization. The aim of our study was to investigate the safety and effectiveness of LAA closure in preventing arterial thromboembolism in a very high-bleeding risk group, such as HHT patients, who are at risk not to tolerate even the mild postprocedural antithrombotic therapy usually recommended.
METHODS: Eight HHT-affected patients with non-valvular AF, high-bleeding risk and/or known intolerance to antiplatelet and anticoagulant therapy were treated with interventional LAA occlusion with the Amplatzer™ Cardiac Plug™ and Amplatzer™ Amulet™ devices. Device implantation was successful in all patients.
RESULTS: Postprocedural antiplatelet/anticoagulation therapy was attempted in seven patients: adherence to therapy exceeded 6 months only for one, while four patients suspended all antithrombotic medications within 30 days from the procedure due to an increase in bleeding frequency and/or severity and the other two discontinued treatment within 6 months; a single patient was not prescribed any antithrombotic therapy. At a medium follow-up of 22.4±14.3 months no thromboembolic episodes attributable to AF or device related thrombosis were reported. Two deaths were recorded 1231 and 783 days after the procedure which were classified as unrelated to any cerebral or cardiovascular accident.
CONCLUSIONS: Our study suggests that the percutaneous LAA closure in HHT patients with AF could be safe and effective in preventing arterial systemic thromboembolism, also in the presence of reduced or absent postinterventional antithrombotic treatment. LAA occluder implantation can represent a valid and potentially life-saving alternative to lifelong anticoagulant therapy in HHT, as in other very high-bleeding risk patients.

KEY WORDS: Telangiectasia, hereditary hemorrhagic; Atrial fibrillation; Anticoagulants