Left atrial appendage thrombus formation despite oral anticoagulation: what can we do when there is nothing to offer?

Objective: Atrial fibrillation (AF) is the most common sustained arrhythmia in the general population and the main common cause of embolism of cardiac origin, both brain and systemic. In about 90% of nonvalvular cases the source is the left atrial appendage (LAA), and the usual prevention approach is oral anticoagulation, but sometimes it fails. LAA thrombus is a classical contraindication to perform procedures in the left atrium. The aim of the study was to share experience with closure of LAA in patients with AF and with left atrial thrombus. Methods: We present our prospective experience from January 2021 to January 2023 with 11 patients of 275 patients referred for AF ablation, who presented thrombus in the computed tomography scan previous the procedure. Modifications of the usual LAA occlusion technique (no touch technique and brain protection) was used. Results: All patients were subjected to LAA occlusion with good success, without complications as leaks, device related thrombus, stroke or systemic embolism. Only one vascular access complication was seen. Different therapeutic strategies are discussed, including intensification of anticoagulation. Conclusions: In patients with nonvalvular AF and failure of anticoagulation, primary percutaneous LAA closure is a possible therapy using specific techniques of image analysis, programming and performance of the procedure. More studies are needed in order to validate this therapy.