A 76-Year-Old Man With Hemorrhagic Stroke, Recurrent Thromboembolic Events, and Atrial Fibrillation Under Optimal Medical Treatment: When Anticoagulants Fail.

The current article demonstrates the clinical case of a 76-year-old man suffering from atrial fibrillation and encountering multiple thromboembolic events. Various novel anticoagulants in therapeutic doses were implemented and proved unsuccessful in preventing stroke, despite good compliance. Due to exclusion of alternative origins of thromboembolism and unfavorable interactions with the patient's medication, he was started on warfarin. He experienced a major intracranial hemorrhage, leading to cessation of antithrombotics for six weeks. Given the increased ischemic risk and scarcity of available options, he was scheduled for implantation of a Watchman left atrial appendage (LAA) occluder (Boston Scientific, Marlborough, MA, USA). Postprocedurally, the antithrombotic regimen comprised enoxaparin for six weeks, followed by dual antiplatelet therapy with aspirin and clopidogrel for six months once complete device endothelialization was confirmed, and finally lifelong aspirin monotherapy. To date, during a six-year follow-up period, the patient has not experienced hemorrhagic or thromboembolic events. Thus, our case report indicates that LAA occlusion could constitute a successful alternative method of stroke prevention in individuals with high ischemic risk despite optimal medical therapy or with contraindications to anticoagulation.