Safety of rhythm control and cardioversion for patients with recurrent symptomatic atrial fibrillation in the absence of anticoagulation following percutaneous left atrial appendage occlusion
Shah R, Al-Darzi W, Greenbaum A, Eng M, Wang DD, Greenberg J, Lahiri M, Khan A, O'Neill WW, Schuger C, Singh G. Safety of rhythm control and cardioversion for patients with recurrent symptomatic atrial fibrillation in the absence of anticoagulation following percutaneous left atrial appendage occlusion. J Am Coll Cardiol. 2018;71(11)
J Am Coll Cardiol
Background: For patients with atrial fibrillation (AF) and contraindication to anticoagulation, percutaneous left atrialappendage occlusion (pLAAO) followed by immediate antiplatelet therapy is a proposed method to reduce both stroke (CVA) and hemorrhagic complications. In such patients who have undergone pLAAO, there is no long-term data regarding the safety of cardioversion (CDV) and rhythmcontrol strategies post occlusion for recurrence of AF symptoms in the absence of anticoagulation. Methods: Retrospective review of 264 patients with AF and contraindications to chronic anticoagulation who underwent successful pLAAO from 6/2012 to 5/2017. From this cohort 12 patients were identifed who had recurrence of symptomatic arrhythmia after previously implanted occluder device [11 Watchman, 1 Amplatzer] and underwent CDV or rhythm control measures. Outcomes ofCVA or transient ischemic attack (TIA), left atrial or device thrombus, new device leak or device embolization, and all-cause mortality were identifed. Results: Mean age was 69.9 years [58-81], 42% female, mean CHA2DS2VASc was 5.5 [+/-1.3], and 75% of the population had CVA prior to pLAAO. Median time from LAA occlusion to CDV was 4.4 months. Four patients received CDV within 30 days of occlusion. Ten of 12 patients were treated with only antiplatelet therapy following CDV; 5 of 10 with single agent aspirin; latter 2 patients treated with brief warfarin. All 12 patientsunderwent dedicated imaging with assessment of occluder device at successful conversion to sinus rhythm. In total, 6 patients received direct current CDV (200-300J), 3 patientsunderwent ablation, and 3 patients had pharmacologic CDV prior to intended direct current. During a period of 208 patient-months [median 17.3] there were: 0 CVA/TIA, 0 device or LA thrombus, 0 device dislodgements or new device leaks, and 2 non-cardiovascular mortalities. Conclusion: To the best of our knowledge, this is the frst report documenting the safety of cardioversion and rhythmcontrol measures in high-risk patients (elevated CHA2DS2VASc) with AF status post percutaneous LAA occlusion in the absence of anticoagulation.