NEW OAC OR LAAC IF A PATIENT BLEEDS ON OAC? PRO LAAC Boris Schmidt, FHRS Cardioangiologisches Centrum Bethanien (CCB) Frankfurt am Main, Germany

DISCLOSURES Activity Company Advisory Board Boston Sci Abbott Research Grant Biosense Webster CardioFocus Medtronic Lifetech Speaker‘s Honoraria

IF PATIENT BLEEDS - PRO LAAC OUTCOME AFTER BLEEDING – ORBIT AF Steinberg BA et al. Am J Cardiol 2017;119:1590e1595)

IF PATIENT BLEEDS - PRO LAAC MANAGEMENT AFTER BLEEDING – ORBIT AF Steinberg BA et al. Am J Cardiol 2017;119:1590e1595)

IF PATIENT BLEEDS - PRO LAAC IF A PATIENT BLEEDS ON VKA HR 0.73; P=0.04 LAO 40° Reddy V et al. J Am Coll Cardiol. 2017 Dec 19;70(24):2964-2975

GI BLEEDING –RESUMPTION OF OAC? IF PATIENT BLEEDS - PRO LAAC GI BLEEDING –RESUMPTION OF OAC? Steffel J et al. European Heart Journal (2018) 39, 1330–1393

HX OF ULCER–RESUMPTION OF OAC? IF PATIENT BLEEDS - PRO LAAC HX OF ULCER–RESUMPTION OF OAC? Lee SJ J et al. Am J Cardiol 2012

INTRACRANIAL BLEEDING –RESUMPTION OF OAC? IF PATIENT BLEEDS - PRO LAAC INTRACRANIAL BLEEDING –RESUMPTION OF OAC? Annual re-ICH rate under OAC 5% Metananlysis….Neurology 2017;89:687–696. Steffel J et al. European Heart Journal (2018) 39, 1330–1393

IF PATIENT BLEEDS - PRO LAAC ESC RECOMMENDATION Particularly for severe and life-threatening bleedings without a clear secondary or reversible/treatable cause the risks of re-initiating anticoagulation may outweigh the benefits. In such cases, implantation of a left atrial appendage (LAA) occluder (…)may be considered (…). Steffel J et al. European Heart Journal (2018) 39, 1330–1393

IF PATIENT BLEEDS - PRO LAAC GLOBAL AMULET REGISTRY n=1088 61 centres in Europe, Australia, Israel, Chile and Hong Kong. 6/15-9/16 Landmesser U et al. EuroIntervention. 2017 Sep 20;13(7):867-876.

IF PATIENT BLEEDS - PRO LAAC MAJOR BLEEDING –LAAC ? 72% of patients with Hx of bleeding. Annual Bleeding rate 10.3%/yr _> no ICH !! 30% periprocedural bleeding Landmesser U et al. EuroIntervention. 2017 Sep 20;13(7):867-876.

IF PATIENT BLEEDS - PRO LAAC NOVEL POST-IMPLANT STRATEGIES – 6 WKS DAPT Device-related thrombosis was detected in 2/107 (1.9%) cases In 5/256 (2.0%) patients on DAPT, DRT was detected (WATCHMAN and WATCHMAN FLX, n=3; AMPLATZER Cardiac Plug and Amulet, n=2). Weise FK et al. EuroIntervention 2018;13:e2138-e2146

IF PATIENT BLEEDS - PRO LAAC CHANGES IN MEDICATION DURING FU Device-related thrombosis was detected in 2/107 (1.9%) cases In 5/256 (2.0%) patients on DAPT, DRT was detected (WATCHMAN and WATCHMAN FLX, n=3; AMPLATZER Cardiac Plug and Amulet, n=2). Boersma L et al. ESC 2018

IF PATIENT BLEEDS - PRO LAAC RRR FOR VARIOUS SUBGROUPS -EWOLUTION Device-related thrombosis was detected in 2/107 (1.9%) cases In 5/256 (2.0%) patients on DAPT, DRT was detected (WATCHMAN and WATCHMAN FLX, n=3; AMPLATZER Cardiac Plug and Amulet, n=2). Boersma L et al. ESC 2018

IF PATIENT BLEEDS - PRO LAAC COMPLIANCE - NOAC % DISCONTINUED

IF PATIENT BLEEDS - PRO LAAC COMPLIANCE - LAAC

IF PATIENT BLEEDS - PRO LAAC CONCLUSION – IF PATIENT BLEEDS ON OAC MARKS FOR HIGH RISK SITUATION LAAC PREFERABLE OVER OAC UNLESS REVERSIBLE CAUSE LOW-INTENSITY OR SHORT DURATION APT FEASIBLE LAAC PROVIDES UNINTERRUPTED PROPHYLAXIS