CONGRESS ABSTRACT

Clinical case An 83-year-old woman with a hypertension, dyslipidemia and primary biliary cirrhosis, presented, several years ago, an acute myocardial infarction treated with PCI on anterior descending artery (LAD). In the following years due to persistent inducible ischemia and chest pain, she underwent another PCI with stenting of circumflex and LAD. From 2021 she was in persistent atrial fibrillation and she started anticoagulant therapy with DOAC. In December 2023, for severe anemia from colon angiodysplasia, she discontinued DOAC’s therapy. Patient was with high thrombotic risk (CHA2DS2-VASc score 6) and high hemorrhagic risk (HAS-BLED 4) so she was underwent to left atrial appendage closure (LAAC) with Amplatzer 25 mm device. She received DAPT with acetylsalicylic acid and clopidogrel. At 6-months follow-up, TEE revealed a device well positioned in LAA without significant leaks, with a thrombus in the atrial portion of the disc so the patient started a therapy with LMWH and aspirin. After 6 weeks the patient was asymptomatic and a TEE showed a complete resolution of the device related thrombosis (DRT). We decided to follow this antithrombotic therapy for other 6 weeks and after we planned another TEE 3 months later only with aspirin treatment. Discussion DRT occurs in 3-7% of patients after LAAC (1) and it is an independent risk factor for ischemic stroke during follow-up. Development of a DRT depends on patient characteristics and thrombosis risk factors: like higher CHADS-VASc score and deep device implantation (2). Due to the asymptomatic nature of patients, determining the exact time of thrombus formation is challenging, as DRT is often detected during follow-up imaging after the LAAC. Once diagnosed, anticoagulation with LMWH or Warfarin is the standard treatment, though the optimal regimen and duration remain uncertain (3). Observational studies show that anticoagulation resolves DRT in over 95% of cases. Current evidence suggests that a low-dose of DOAC-only or SAPT could be evaluated for each case balancing the thrombo-embolic and bleeding risk of the single patient. Several randomized trials are currently underway and could contribute to further refining this personalized approach (4) 1) Garot P et al. Int. Card. 2019 Feb;14(1):42-44 2) Dukkipati SR et al. Circ. 2018 Aug 28;138(9):874-885 3) Wunderlich NC et al. Cur Card Rep. 2020 Aug 8;22(10):113.  4) Mohamad Alkhouli et al. JACC: Cardi. Inter., Volume 16, Issue 22, 2023, Pages 2695-2707