Given her recurrent GI bleeds and ongoing risk factors for thromboembolism in the setting of persistent AF, this patient meets indications for oral anticoagulation. However, with the recurrent bleeding, this is relatively contraindicated. Therefore, she would be a good candidate for a left atrial appendage occlusion device (ie, Watchman device), which has been approved for patients with non-valvular AF as an alternative to warfarin therapy for reducing the risk of stroke.
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. JACC. 2014;64: 2246-2280.
Wyse GD, Van Gelder IC, Ellinor PT, et al. Lone atrial fibrillation: does it exist? [white paper]. JACC. 2014;63:1715-1723