Percutaneous Left Atrial Appendage Closure in Patients With Cardioembolic Breakthrough Stroke: An International Observational Study

Background: Patients with non-valvular atrial fibrillation (AF) who experience an ischemic stroke despite oral anticoagulation (OAC) are at particularly high risk of recurrence, with a reported annualized ischemic stroke rate of 5.3%–8.9%. The optimal strategy for secondary prevention in these patients remains unknown. Methods: We reviewed all percutaneous left atrial appendage closures (LAAC) attempted in AF patients experiencing an ischemic stroke under OAC and who were prospectively collected in four European centers. All index strokes were categorized by an experienced neurologist to exclude patients with non-cardioembolic etiology or insufficient OAC. The primary endpoint was a recurrent ischemic stroke at 2 years after the procedure. Secondary endpoints included procedure-related complications and 2-year death. Results: Of 2234 patients submitted to LAAC procedure, 95 had a cardioembolic breakthrough stroke. LAAC procedures were performed at a mean of 4 months after the breakthrough stroke. The main antithrombotic therapy at discharge (83%) and at the latest follow-up (79%) consisted of OAC. At the median follow-up of 713 days, the primary endpoint occurred in 4 patients (4%). Procedure-related complications were rare (1%) whereas death occurred in 5% of patients. Conclusion: LAAC procedures were safe and feasible in patients with cardioembolic breakthrough stroke. Recurrent stroke rates were lower than those reported in previous studies with OAC continuation after breakthrough stroke, suggesting a potential additive protection by LAAC on top of OAC. Results from ongoing randomized trials are required to validate our findings.