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Antithrombotic Regimens After Left Atrial Appendage Occlusion
Quick Takes
- The use of DOAC therapy is associated with the lowest risk of both thromboembolism and major bleeding following LAAO.
- DAPT therapy is associated with lower rates of thromboembolism and similar rates of major bleeding as SAPT for patients undergoing LAAO.
- Selecting the most appropriate antithrombotic regimen after LAAO should be informed by a bleeding history and assessment of bleeding risk factors.
Study Questions:
What is the safety and efficacy of various antithrombotic strategies after left atrial appendage occlusion (LAAO) in patients with nonvalvular atrial fibrillation (AF)?
Methods:
The authors performed a systematic literature search for randomized and observational studies comparing 2+ antithrombotic regimens for patients with nonvalvular AF undergoing LAAO using endocardial or epicardial devices. Key antithrombotic regimen studies included direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), and combinations of DOAC or VKA with SAPT. The primary efficacy outcome was device-related thrombosis. All-cause mortality and major bleeding were also assessed.
Results:
Forty-one studies comprising 12,451 patients met the study inclusion criteria. DAPT, DOAC, DOAC plus SAPT, and VKA therapy regimens were all superior to no therapy at preventing device-related thrombosis. DOAC therapy was associated with a lower all-cause mortality compared to VKA (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.17-0.89). DAPT was associated with fewer thromboembolic events (OR, 0.50; 95% CI, 0.29-0.88) without a difference in major bleeding as compared to SAPT. Looking across all therapy options, DOAC therapy was most likely to have lower thromboembolic and major bleeding risk.
Conclusions:
The authors conclude that DOAC monotherapy had the highest likelihood of lower thromboembolic events and major bleeding for patients undergoing LAAO for nonvalvular AF.
Perspective:
LAAO is an increasingly common procedure to reduce stroke and systemic embolism risk for patients with nonvalvular AF, particularly those at high risk for anticoagulant-related bleeding. While the initial studies required VKA and/or DAPT antithrombotic therapies shortly after LAAO implantation, several other antithrombotic regimens have been tested. In this network meta-analysis, DOAC monotherapy appears to have the lowest overall risk of thromboembolism and bleeding. For patients who cannot tolerate anticoagulant therapy, DAPT was associated with lower thromboembolic risk but similar bleeding risk as SAPT. As clinicians consider the most appropriate antithrombotic regimen following LAAO, taking a detailed bleeding history and assessing for any modifiable bleeding risk factors (e.g., use of NSAID medications) is critical. Most patients undergoing LAAO will likely benefit from DOAC monotherapy or DAPT post-procedure.
Clinical Topics: Anticoagulation Management, Anticoagulation Management and Atrial Fibrillation
Keywords: Anticoagulants, Atrial Appendage, Thromboembolism
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