CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 4, May 2013
AFRICA
107
Cardiovascular Topics
Left atrial appendage closure in patients with atrial
fibrillation in whom warfarin is contra-indicated:
initial South African experience
MARK ABELSON
Abstract
Atrial fibrillation is a common cause of cardiac embolic
events, especially stroke. Oral anticoagulation therapy is used
to reduce these events. Many patients however are unable to
take such therapy. Percutaneous occlusion of the left atrial
appendage (the source of 90% of these emboli) is an option
in these patients. Presented here are the first 12 patients to
have this procedure done in South Africa.
Keywords:
atrial fibrillation, warfarin, left atrial appendage plug
Submitted 4/12/12, accepted 18/3/13
Cardiovasc
J Afr
2013;
24
: 107–109
DOI: 10.5830/CVJA-2013-018
Atrial fibrillation (AF) is the most common cardiac arrhythmia.
1
It is a major cause of morbidity and mortality due to not only
cardio-embolic events such as stroke but also anticoagulant-
related major bleeding complications.
2
The prevalence of AF
increases with age (affecting up to 15% of patients over 80
years) and in patients with predisposing conditions such as
hypertension, diabetes, heart failure and ischaemic heart disease.
1
Approximately 25% of ischaemic strokes are due to cardiac
embolism because of underlying atrial fibrillation.
3
Strokes
in patients with atrial fibrillation are generally larger with a
worse prognosis than in patients without atrial fibrillation.
4
Anticoagulation with the vitamin K antagonist, warfarin, and the
recently available new agents, dabigatran and rivaroxoban, are
indicated to prevent cardiac thrombo-embolism from occurring
in patients with atrial fibrillation and a CHADS
2
/CHADS-Vasc
score
>
1.
5-8
In many patients, however, anticoagulation is contra-indicated
due to high bleeding risk (HASBLED score
>
3),
9
life-threatening
bleeds of unknown cause while on anticoagulation, or due to
perceived frailty and high risk of falls, especially in very elderly
patients.
10,11
Furthermore, INR control of patients on warfarin
is generally poor. This is particularly so in South Africa (South
African patients enrolled in the Active W Trial had the worst
INR control internationally, with
<
50% of patients’ INR in the
therapeutic range), possibly due to no-compliance or interactions
with food, drugs and lifestyle.
12
An alternative approach to prevention of cardiac embolism in
patients withAF is therefore desirable. One that can be used in all
patients and does not require anticoagulation other than low-dose
aspirin. Post-mortem and trans-oesophageal echo studies have
shown that approximately 90% of all cardiac thrombi originate
from the left atrial appendage (LAA) in patients with AF.
13
Surgical exclusion of the LAA at the time of mitral valve surgery
or CABG has been shown to reduce the incidence of cardiac
embolic events in patients with AF.
14
It is on this basis that percutaneous exclusion of the LAA has
been developed, initially using the Plato device
15
(no longer in
production) and followed by the Watchman (Boston Scientific)
16
and the Amplatzer CardiacPlug (ACP) (St Jude) devices.
17-19
This article reports the initial safety, feasibility and clinical
follow up after ACP implantation for non-valvular AF in the first
12 patients to be operated on in South Africa.
Methods
Twelve consecutive patients who received LAA occlusion with
the ACP from November 2010 were prospectively studied.
All patients had permanent atrial fibrillation of more than six
months’ duration and a CHADS-Vasc score of
>
2. All had a
major contra-indication to anticoagulation. All but one patient
had experienced at least one major bleed, requiring blood
transfusion, despite a therapeutic INR. Patient characteristics are
shown in Table 1. No patients were on warfarin at the time of the
Vergelegen Mediclinic, Somerset West, South Africa
MARK ABELSON, MB BCH, MRCP (UK), FCP (SA), mark@helder-
bergheart.co.za
TABLE 1. PATIENT CHARACTERISTICS
Patient Age Gender Type of AF CHADS
2
-Vasc
Wafarin
contra-indication
1 73 Male Permanent 5 (age, PVD, CCF,
stroke)
Gastric bleed, labile INR
2 75 Male Permanent 5 (age, HPT, stroke)
Stroke on warfarin, labile
INR
3 75 Male Permanent 5 (age, DM, IHD, CCF) Major GI bleed
4 82 Male Permanent 6 (age, stroke, HPT,
PVD)
Recurrent major epistaxis
5 79 Male Permanent 2 (age)
Recurrent major GI bleed
6 67 Male Permanent 3 (age, HPT, IHD)
Major GI bleed
7 54 Male Permanent 3 (DM, HPT, CCF)
Major GI bleed
8 61 Male Permanent 3 (DM, HPT, IHD)
Major GI bleed
9 61 Male Permanent 2 (HPT, CCF)
Active ulcerative colitis
10 62 Female Permanent 3 (female, stroke)
Labile INR
11 68 Male Permanent 4 (age, HPT, IHD, DM) Massive retroperitoneal
bleed
12 65 Male Permanent 4 (age, HPT, stroke)
Spontaneous subdural
haemorrhage
