Left atrial appendage occlusion (LAAO) was associated with a lower rate of a composite of ischemic stroke, systemic embolism (SE), major bleeding or all-cause mortality when compared with oral anticoagulation (OAC) with apixaban and warfarin for treating patients with end-stage renal disease (ESRD) who also have atrial fibrillation (AFib), according to a study published Oct. 14 in JACC: Cardiovascular Interventions.

In what they believe is the largest propensity-matched analysis of patients with both ESRD and AFib to date, Abdullah Al-Abcha, MD, et al., used data from 14,849 patients included in the United States Renal Data System registry to compare outcomes of these three stroke prevention strategies. Data were collected from January 2016 through December 2020. The primary endpoint was a composite of major bleeding, ischemic stroke or SE, or death.

Of the included patients (43% women, all ≥18 years old), 16%, 28% and 57% were treated with LAAO, apixaban and warfarin, respectively. Median follow-up was 0.9 years and after propensity score matching, 1,947 patients were included in each group. Of note, patients treated with LAAO were older and had significantly higher rates of cardiovascular morbidities, previous cardiac arrest, liver disease, lung disease, history of stroke, major bleeding, intercranial hemorrhage and coagulation defect.

Results showed that the composite outcome was significantly higher in patients treated with warfarin vs. LAAO (adjusted hazard ratio [HR], 1.26; p<0.001) and apixaban vs. LAAO (adjusted HR, 1.27; p<0.001). Looking at secondary endpoints, the rates of major bleeding, gastrointestinal bleeding, stroke or SE were higher among patients receiving apixaban or warfarin, but the rates of all-cause mortality and intercranial hemorrhage were similar across all groups.

Al-Abcha and colleagues describe their findings as an "important first step" regarding the safety and efficacy of LAAO. "Future studies should also focus on optimizing procedural safety, postprocedural antithrombotic strategies and long-term outcomes in ESRD patients undergoing LAAO," they write.

"While acknowledging limitations inherent to observational data, these findings support a growing role for LAAO as a potentially safer and effective alternative to oral anticoagulation," writes Ingo Eitel, MD, in an accompanying editorial comment. Eitel notes that "…clinicians should consider integrating LAAO more proactively into the management algorithm of high-risk [ESRD] patients with [AFib]."