Left atrial appendage occlusion with the Watchman device in a patient with paroxysmal atrial fibrillation and intolerance of all forms of anticoagulation due to hereditary haemorrhagic telangiectasia

An elderly woman presented to our attention because of paroxysmal atrial fibrillation and cerebrovascular events requiring systemic anticoagulation and a concomitant, serious bleeding diathesis (the Osler-Weber-Rendu syndrome, or hereditary haemorrhagic telangiectasia). Her risk of suffering a major stroke was significant given a CHA(2)DS(2)VASc score of 6. However, she was unable to tolerate any form of anticoagulation because of torrential epistaxis and previous gastrointestinal haemorrhage on antiplatelet therapy. We proceeded with percutaneous occlusion of the left atrial appendage with a Watchman device. Ten months post-procedure she is well, without recurrence of neurological symptoms, and off all forms of anticoagulation. The current internationally accepted practice post-deployment of the Watchman device mandates warfarin transition for 6 months to allow for endothelialisation of the device. However, there is no evidence in the literature to support left atrial appendage occlusion without any peri-procedural antiplatelet and anticoagulation therapy and therefore our case represents novel and important anecdotal evidence that secondary stroke prevention with left atrial appendage occlusion may be effective and safe even in patients who cannot tolerate any form of anticoagulation at all.