Ischemic and Bleeding Outcomes Following Left Atrial Appendage Closure in Patients with Prior Intracerebral Hemorrhage: A Retrospective Inverse Probability Weighting Analysis from the BRA-LAAC Registry

Background: Intracerebral hemorrhage (ICH) is a severe complication in patients with atrial fibrillation (AF), increasing the risk of ischemic events and recurrent bleeding. Percutaneous left atrial appendage closure (LAAC) is an alternative for stroke prevention in AF patients with contraindications to oral anticoagulation, such as ICH. However, its safety and efficacy in this population remain underexplored, particularly in the Brazilian context. Methods: The BRA-LAAC registry, a multicenter retrospective study conducted in Brazil from 2016 to 2023, included consecutive patients undergoing LAAC. Patients were stratified by prior ICH history (ICH vs. non-ICH). Safety and efficacy outcomes, including mortality, major adverse cardiovascular events (MACE), bleeding, and re-hospitalization, were assessed at 3 and 12 months post-procedure. Inverse probability weighting (IPW) and Cox proportional hazard models were used to adjust for confounders. Results: Of 512 patients (mean age 72.4 ± 8.9 years, 58% male), 18.4% (n=94) had prior ICH. The composite endpoint of death, MACE, and bleeding was significantly lower in the ICH group (HR 0.42, 95% CI 0.08–2.19, p=0.03), driven by reduced bleeding events (HR 0.31, 95% CI 0.07– 1.38, p=0.02). Re-hospitalization rates were also lower in the ICH group (HR 0.39, 95% CI 0.22– 0.69, p=0.001). After IPW adjustment, no significant differences were observed in mortality (HR 0.61, 95% CI 0.19–1.97, p=0.41), stroke (HR 0.38, 95% CI 0.04–3.61, p=0.39), or MACE (HR 0.34, 95% CI 0.05–2.29, p=0.01), though bleeding remained lower (HR 0.29, 95% CI 0.06–1.41, p=0.03). Conclusion: LAAC appears safe and effective in Brazilian patients with prior ICH, with reduced bleeding and re-hospitalization rates compared to non-ICH patients. These findings support LAAC as a viable strategy in high-risk populations but require validation through randomized controlled trials.