CO-50 | LEFT ATRIAL APPENDAGE OCCLUSION IN PATIENTS WITH ATRIAL FIBRILLATION AND BLEEDING DISORDERS: A SINGLE-CENTER EXPERIENCE

B.M. Roccon¹, M.I. Tassoni¹, G. Quintavalle¹, G. Benatti², F. Gurgoglione², R. Rossi³, C. Cattabiani³, L. Vignali², A. Tagliaferri¹, A. Coppola¹ | ¹SSD Centro Hub Emofilia e Malattie Emorragiche Congenite, Azienda Ospedaliero-Universitaria di Parma, Italy; ²SSD Cardiologia Interventistica, Azienda Ospedaliero-Universitaria di Parma, Italy; ³Laboratorio di Coagulazione, UOC Patologia Clinica, Azienda Ospedaliero-Universitaria di Parma, Italy

Introduction. Data about the management of atrial fibrillation (AF) in patients with hemophilia and other bleeding disorders (BD) are limited. The reliability of stroke risk scores (i.e. CHA2DS2VASc), used in the general population for treatment choices, and long-term safety of anticoagulation, as well the need for concomitant hemostatic prophylaxis, remain unknown. Left atrial appendage occlusion (LAAO) has been suggested as an alternative to anticoagulation in patients with high bleeding risk, few cases being reported even in BD.
Methods. Retrospective review of patients with BD and AF who underwent LAAO at the University Hospital of Parma.
Results. Eight patients were identified, 6 males and 2 females, aged 64-80 yrs (Table). Mean CHA2DS2VASc was 4 (range 2-5). Two men had mild factor VII deficiency, both on aspirin (ASA) 100 mg/d because of history of myocardial revascularization due to diffuse coronary artery disease. Combined antiplatelet-anticoagulation treatment was considered in both patients after AF diagnosis, due to very high cardiovascular and stroke risk; the concomitant bleeding risk led to consider LAAO. Three elderly men with hemophilia A (2 severe, 1 moderate) on tertiary prophylaxis were reluctant to any long-term antithrombotic treatment. A moderate hemophilia B patient treated on demand developed AF in the setting of severe chronic heart failure. The two female patients had a type 2A von Willebrand disease (VWF:RCo 10%) and an acquired von Willebrand syndrome (AVWS, VWF:RCo 5%; concomitant detection of monoclonal gammopathy of uncertain significance). In all patients but one the Amplatzer plug was successfully implanted; heparinization was managed with specific replacement treatment, achieving factor levels ≥80% during and up to 24h after the procedure. One patient experienced mild pericardial effusion. No thromboembolic events were observed. Overall, bleeding episodes occurred In 5/8 cases. Patients with mild FVII deficiencies received double antiplatelet treatment for 3-6 months reporting mild mucocutaneous bleeding, then remained on ASA. Single antiplatelet treatment and FVIII personalized prophylaxis (FVIII trough >5-10%) were used in the 3 hemophiliacs, one withdrew clopidogrel after 2 months due to severe epistaxis and joint bleeds. No relevant bleeding occurred in the old men on anticoagulation, made possible by sustained prophylaxis with extended half-life FIX, nor in the two women with VWF abnormalities on ASA (the AVWS patient received VWF-FVIII concentrate prophylaxis for 4 months).
Conclusions. Adequate factor levels to allow safe antithrombotic treatments in BD patients remain uncertain. LAAO, when performed at experienced facilities, is a safe alternative to anticoagulation in BD with AF-related stroke risk.