Among Patients Receiving Transcatheter Aortic Valve Replacement, Who Are the Best Candidates for Left Atrial Appendage Occlusion?
The best candidates for LAA occlusion with TAVR are those with chronic atrial fibrillation and established contraindications to anticoagulation or a high bleeding risk (i.e. for both warfarin-ineligible and warfarin-eligible patients). Many patients who are candidates for TAVR have a high bleeding risk and are often withheld warfarin, making them preferential candidates for LAA occlusion.42 Other candidates include those patients with a high risk of drug–drug interaction or warfarin non-compliance. Patients with coronary artery stenting that need dual antiplatelet therapy also benefit from being off warfarin and being treated with LAA occlusion; this removes the risk of prolonged anticoagulation and/or triple therapy.
Patients that have to take warfarin for other reasons should not be candidates for LAA occlusion (e.g. patients with pulmonary embolism, deep vein thrombosis or haematological abnormality).
When should LAA closure happen? There is evidence that this can be done in the same setting as TAVR, as reported in 10 % of patients in a case series published by Nietlispach et al.43 Multiple case reports have also demonstrated safety of TAVR immediately followed by LAA occlusion.44–46 This takes advantage of transoesophageal guidance (and if used, general anaesthesia) for both procedures. In addition, the patients may be able to tolerate a LAA occlusion complication (e.g. embolisation45 and tamponade) if the aortic valve obstruction has been treated prior (personal communication, Fabien Nietlispach, 10 April 2014). Other centres have performed TAVI first with LAA occlusion to follow.47
In the case of chronic atrial fibrillation, the TAVR should be performed first as this is the more clinically important intervention. In addition, there is no evidence to show that LAA closure will change the procedural stroke rate. LAA closure may take place immediately or early within the first month after TAVR to prevent intermediate and late stroke. For centres that plan to do both in the same setting, this requires careful patient selection, planning and operator experience. In this case, the dual antiplatelet therapy that is used for TAVR may also be used for post-LAA occlusion management.