Implantación percutánea de dispositivo WATCHMAN en paciente con fibrilación auricular y contraindicación para anticoagulación

Juliana Salas Segura
Departamento de Cardiología, Hospital Clínica Bíblica, San José, Costa Rica.

Esteban Zavaleta Monestel
Departamento de Investigación, Hospital Clínica Bíblica, San José, Costa Rica.

Adriana Anchía Alfaro
Departamento de Investigación, Hospital Clínica Bíblica, San José, Costa Rica.

Resumen

Introducción: La fibrilación auricular (FA) incrementa el riesgo de accidente cerebrovascular, y el apéndice auricular izquierdo (AAI) es el principal origen de los trombos. El cierre percutáneo del AAI con dispositivos como el WATCHMAN constituye una alternativa en pacientes con contraindicación a la anticoagulación sistémica. Caso: Se presenta un paciente masculino de 85 años con FA crónica, cardiopatía dilatada, hipertensión, EPOC y episodios de hemorragia grave asociados al uso de anticoagulantes. Con un puntaje CHA₂DS₂-VASc = 3 y HAS-BLED = 4, se decidió implantar un dispositivo WATCHMAN FLX. El procedimiento se realizó sin complicaciones, con fijación adecuada, confirmada mediante ecocardiografía transesofágica. El paciente fue dado de alta con terapia antiplaquetaria dual durante seis meses. Discusión: Los ensayos clínicos han demostrado que WATCHMAN no es inferior a la anticoagulación oral en la prevención de eventos tromboembólicos, con un menor riesgo de hemorragia a largo plazo. En pacientes con alto riesgo de sangrado, la estrategia de terapia dual antiplaquetaria, seguida de aspirina en monoterapia, constituye una alternativa segura y eficaz. Este caso destaca la utilidad del cierre percutáneo del AAI en contextos clínicos complejos en los que la anticoagulación no resulta viable. Conclusión: La implantación del dispositivo WATCHMAN es una opción efectiva y segura para prevenir accidentes cerebrovasculares en pacientes con FA y contraindicación a la anticoagulación.

Palabras claves

Fibrilación Auricular, Cierre del Apéndice Auricular Izquierdo; Anticoagulantes; Contraindicaciones de Medicamentos; Accidente Cerebrovascular (ACV).

Abstract

Background: Atrial fibrillation (AF) increases the risk of ischemic stroke, with the left atrial appendage (LAA) being the primary source of thrombus formation. Percutaneous LAA closure with devices such as WATCHMAN provides an alternative for patients with contraindications to long-term anticoagulation. Case: We report the case of an 85-year-old male with chronic AF, dilated cardiomyopathy, hypertension, chronic obstructive pulmonary disease (COPD), and recurrent severe bleeding events associated with oral anticoagulants. With CHA₂DS₂-VASc = 3 and HAS-BLED = 4, he underwent implantation of a WATCHMAN FLX device. The procedure was successful, with proper fixation confirmed by transesophageal echocardiography. He was discharged on dual antiplatelet therapy for six months. Discussion: Clinical trials have shown that WATCHMAN is non-inferior to oral anticoagulation in preventing thromboembolic events, with a reduced long-term risk of significant bleeding. In high-bleeding-risk patients, dual antiplatelet therapy followed by aspirin monotherapy represents a safe and effective strategy. This case exemplifies the clinical value of percutaneous LAA closure in complex scenarios where anticoagulation is not feasible. Conclusion: WATCHMAN implantation is an effective and safe option for stroke prevention in AF patients with contraindications to oral anticoagulation.

Keywords

Atrial Fibrillation, Left Atrial Appendage Closure, Anticoagulants, Drug Contraindications, Stroke.

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