Background: The presence of left atrial appendage (LAA) thrombus precludes endocardial LAA occlusion, but there are scant data on the management of these very high-risk atrial fibrillation (AF) patients. Our aim was to evaluate the efficacy and safety of short-term apixaban treatment for LAA thrombi detected prior to planned LAA occlusion
in patients with contraindications to long-term oral anticoagulant
Methods: We report the short- and long-term outcomes on AF patients who had LAA thrombi documented on pre-procedural imaging prior to their LAA occlusion procedure.
Results: Among 87 patients who underwent workup for LAA occlusion, LAA thrombi were documented in 11 patients on pre-procedural imaging (nine on trans-oesophageal echocardiography and two on cardiac computed tomographic angiography). They comprised of seven (63.6%) males with a mean age of 76.9 (±6.9) years. Every patient had permanent AF. The median CHA2DS2-VASc and HAS-BLED scores were 4.0 (3.0 – 5.0) and 2.0 (2.0 – 3.0) respectively. Contraindications to long-term OAC were prior intracranial haemorrhage while on OAC (n=4) and despite no OAC (n=2), prior gastrointestinal haemorrhage while on OAC (n=2) and despite no OAC (n=1), severe unexplained anaemia on dabigatran (n=1), and failed OAC (n=1). Before enrolment, none of the patients were receiving OAC and four (36.4%) patients were on an antiplatelet agent. Appropriate dose-adjusted apixaban was prescribed for each patient and repeat imaging scheduled at 6-8-week intervals. Complete resolution of LAA thrombus was observed in 10 (90.9%) patients after 94 (IQR 44 – 126) days, all of whom underwent LAA occlusion safely with no peri-procedural complications. During treatment with apixaban, one patient had severe gastrointestinal bleeding requiring blood transfusion and one patient suffered an ischaemic stroke with subsequent full recovery. One patient had persistent LAA thrombus on repeated imaging and a patient-centred decision was taken for long-term apixaban therapy; no bleeding complications were observed over a follow-up of 25 weeks. Among the 10 patients who received LAA occlusion, no device-related thrombus was observed on follow-up imaging (eight by trans-oesophageal echocardiography and two by cardiac computed tomographic angiography). Over a median follow-up of 129 (33 – 169) weeks, one patient had a transient ischaemic attack and one patient had an episode of severe epistaxis despite not being on antiplatelet or OAC therapy. Four (40%) patients died.
Conclusion: Short-term treatment with apixaban appears to be effective and relatively safe for high-risk AF patients with documented LAA thrombi who are ineligible for long-term OAC therapy. This allows the LAA occlusion procedure to be undertaken safely.