Brendan Gunalingam

Left atrial appendage occlusion with the Watchman device in a patient with paroxysmal atrial fibrillation and intolerance of all forms of anticoagulation due to hereditary haemorrhagic telangiectasia

An elderly woman presented to our attention because of paroxysmal atrial fibrillation and cerebrovascular events requiring systemic anticoagulation and a concomitant, serious bleeding diathesis (the Osler‐Weber‐Rendu syndrome, or hereditary haemorrhagic telangiectasia). Her risk of suffering a major stroke was significant given a CHA2DS2VASc score of 6. However, she was unable to tolerate any form of anticoagulation because of torrential epistaxis and previous gastrointestinal haemorrhage on antiplatelet therapy. We proceeded with percutaneous occlusion of the left atrial appendage with a Watchman device. Ten months post‐procedure she is well, without recurrence of neurological symptoms, and off all forms of anticoagulation. The current internationally accepted practice post‐deployment of the Watchman device mandates warfarin transition for 6 months to allow for endothelialisation of the device. However, there is no evidence in the literature to support left atrial appendage occlusion without any peri‐procedural antiplatelet and anticoagulation therapy and therefore our case represents novel and important anecdotal evidence that secondary stroke prevention with left atrial appendage occlusion may be effective and safe even in patients who cannot tolerate any form of anticoagulation at all.

Percutaneous Left Atrial Appendage Occlusion with a Watchman Device Following Recurrent Stroke on Warfarin and Rivaroxaban in Patient with Paroxysmal Atrial Fibrillation

The optimal management of recurrent cardioembolic stroke in a patient on oral anticoagulation is controversial. Therapeutic strategies for secondary stroke prevention in such circumstances may include the intensification of oral anticoagulation, the addition of antiplatelet therapy to warfarin, or the use of a non-vitamin K antagonist instead of warfarin. However, there is no evidence to support these interventions, and indeed these strategies are not endorsed by the 2011 Guidelines on the Secondary Prevention of Stroke issued by the American Heart Association/American Stroke Association. Percutaneous occlusion of the left atrial appendage (LAA) has recently emerged as an acceptable non-pharmacological strategy to reduce the risk of cardioembolism in patients who cannot tolerate oral anticoagulation, but there is little evidence to support its use in the context of recurrent stroke despite oral anticoagulation. We present the case of a 66 year-old male with paroxysmal atrial fibrillation who experienced recurrent stroke despite treatment with warfarin initially, and rivaroxaban subsequently. After excluding non-cardioembolic causes of recurrent stroke, we proceeded with percutaneous occlusion of the LAA with a Watchman device. Nine months post-procedure he has not experienced recurrence of neurological symptoms. Our case provides anectodal evidence that catheter-based LAA occlusion can be beneficial in secondary stroke prevention where oral anticoagulation has been problematic.

PHYSIOLOGICAL EFFECT OF TRANSCATHETER LEFT ATRIAL APPENDAGE OCCLUSION ON ATRIAL AND BRAIN NATRIURETIC PEPTIDES AND SALT WATER HOMEOSTASIS

Background: Atrial natriuretic peptide (ANP), and brain natriuretic peptide (BNP) are produced by mammalian cardiomyocytes located in the atria and atrial appendages. These hormones are released in response to chamber distension, and have potent natriuretic, diuretic, and vasodilator activity.

Primary percutaneous coronary intervention for inferior ST‐segment elevation myocardial infarction in a patient supported by the HeartWare left ventricular assist device

A 63‐year‐old man with an ischaemic cardiomyopathy, supported by the HeartWare left ventricular assist device (LVAD), presented with ventricular tachycardia and inferior ST‐elevation myocardial infarction (STEMI) with associated acute right ventricular (RV) dysfunction. He underwent primary percutaneous coronary intervention with balloon angioplasty and placement of three drug‐eluting stents in the proximal‐to‐mid right coronary artery. Post‐procedure, ventricular arrhythmias abated, RV systolic dysfunction resolved and RV size normalised. Percutaneous coronary intervention (PCI) facilitated by the use of miniaturised percutaneous LVAD has become an increasingly available treatment option for high‐risk patients. PCI in patients on established full mechanical circulatory support is not a common occurrence. Indeed, to our knowledge, this is the first case of primary percutaneous coronary intervention on an LVAD‐supported heart reported in the medical literature. The case raises several specific issues that are of peculiar interest to clinicians involved in the care of patients supported by mechanical assist devices who experience an acute coronary syndrome requiring emergent revascularisation.