Left Atrial Appendage Closure vs Blood Thinners

The short answer

For most people with atrial fibrillation who need stroke protection, a blood thinner is the first choice. And it should stay the first choice. Blood thinners, also called anticoagulants, have decades of randomized trial evidence behind them. They also protect against clots wherever those clots form. Left atrial appendage closure is a catheter procedure. It seals off a small pouch on the left atrium. Most atrial fibrillation clots start in that pouch. The best known device is called the Watchman. Closure is not a general purpose replacement for blood thinners. It exists mainly for patients who have a real reason they cannot stay on them long term. Examples are repeated serious bleeding, a bleeding condition that cannot be fixed, or a high risk of falls with head injury. If you tolerate your blood thinner well, closure usually offers no advantage. If you truly cannot take one, closure gives you a stroke prevention option you would otherwise not have.

How they differ at a glance

Anticoagulant medication in detail

In atrial fibrillation, the upper chambers quiver instead of squeezing. Blood then moves sluggishly, and clots can form. If a clot travels to the brain, it causes a stroke. Blood thinners cut that risk sharply, and they remain the foundation of treatment. The National Heart, Lung, and Blood Institute and the American Heart Association both call this standard care for patients above a set level of stroke risk.

Direct oral anticoagulants have made things much simpler. They need no routine blood testing. They clash with fewer foods than warfarin does. Several have also shown lower rates of bleeding inside the brain. Warfarin is still needed for mechanical heart valves, and for moderate to severe mitral stenosis. The newer drugs are not appropriate there.

The real drawback is bleeding. Any blood thinner that works raises bleeding risk somewhere. Three situations most often make it impossible to continue. They are repeated bleeding in the gut, past bleeding into the brain, and frequent falls. Practical guidance for patients is available from MedlinePlus.

Taking the pills as prescribed also matters. These medicines protect only while they are in your system. Missed doses leave you unprotected.

Left atrial appendage closure in detail

Left atrial appendage closure treats the anatomy rather than the blood. The appendage is a small pouch off the left atrium. It has no known essential job. In non valvular atrial fibrillation, it is the source of the large majority of clots that cause stroke. Sealing it removes that reservoir.

The procedure goes through a vein in the leg. No artery is punctured, and no chest cut is made. Imaging guides the device into the mouth of the appendage. There it expands and stays for good.

Being honest about the caveats matters here. Closure does not treat atrial fibrillation itself. Your rhythm, your heart rate, and your symptoms stay the same. It does not remove stroke risk, since clots can form elsewhere. You will still need some clot preventing medicine for a period after the device goes in, while tissue grows over it. So it is not an immediate exit from all blood thinners. The procedure also carries its own risks. They include fluid collecting around the heart, the device moving, a clot forming on its surface, and leaks around the edges. Trial evidence supports closure as an alternative in appropriate patients. That is why it appears in the American College of Cardiology guideline resources. But it is an option for a specific group, not a general upgrade.

How Dr. Nanavati decides which is right for you

Stroke risk is worked out first. Scoring systems weigh age, sex, heart failure, high blood pressure, diabetes, vascular disease, and past stroke. If your calculated risk is low, neither option may be needed.

Bleeding history decides it for most candidates. Some findings move closure onto the table. They include a documented major bleed on a blood thinner, past bleeding in the brain, a bleeding disorder, or repeated gut bleeding that cannot be fixed.

Next, can the problem be solved another way? Sometimes bleeding comes from an ulcer or polyp that can be treated. Sometimes another drug, or too high a dose, is to blame. Fixing that beats giving up the blood thinner.

Anatomy has to cooperate. The appendage must be a shape and size the device can seal. No clot can already be sitting in it. Imaging confirms this before scheduling. The basic check starts with an office echocardiogram.

Confirming the rhythm matters too. If atrial fibrillation is suspected but not proven, longer rhythm recording comes first. Our Holter vs event monitor page and the arrhythmias page explain those tools. Holter monitoring is performed in the office.

Your values count. Some patients accept a daily pill readily. Others, after a serious bleed, will not restart one under any circumstances. The CDC outlines what is at stake on the stroke side of that decision.

Questions to ask your cardiologist

• What is my calculated stroke risk, and what is my calculated bleeding risk?
• Is there a correctable reason for my bleeding before we abandon anticoagulation?
• Would a different blood thinner, or a dose change, solve the problem?
• If I have the appendage closed, what medicine will I still need, and for how long?
• What are the specific risks in my case, and what does follow up imaging involve?
• Does closure change anything about my heart rhythm or my other medicines?

Talk it through with a cardiologist

Dr. Vimal Nanavati, MD, FACC is board certified in cardiology and interventional cardiology, with 32 years in practice. He founded HeartCare4life in 1997 and sees patients in South San Diego (Bonita), North San Diego, and Redding.

Rhythm monitoring and echocardiography are performed in the office. Catheter based procedures are performed at affiliated hospitals.

Request an appointment online, call South San Diego at (619) 585-0476 or Redding at (530) 433-5427, view all locations, read about Dr. Nanavati, or browse our FAQs.