Left Atrial Appendage Closure vs. Novel Anticoagulation Agents in High-Risk Atrial Fibrillation Patients - PRAGUE-17

Contribution To Literature:

The PRAGUE-17 trial showed that left atrial appendage occlusion was noninferior to a NOAC at preventing net ischemic/bleeding events.


The goal of the trial was to evaluate left atrial appendage occlusion compared with a novel oral anticoagulant (NOAC) among patients with nonvalvular atrial fibrillation.

Study Design

  • Randomized
  • Parallel
  • Open-label

Patients with nonvalvular atrial fibrillation were randomized to left atrial appendage occlusion (n = 201) versus a NOAC (n = 201).

In the left atrial appendage occlusion group, the Amulet or the Watchman device could be used. Patients were treated with dual antiplatelet therapy for 3 months, at which time a transesophageal echocardiogram was performed. If no thrombus, aspirin alone was maintained. Antiplatelet/anticoagulation therapy could be modified depending on bleeding/thrombotic risk.

In the NOAC group, any agent could be given; however, apixaban was preferred.

  • Total number of enrollees: 402
  • Duration of follow-up: 20.8 months
  • Mean patient age: 73 years
  • Percentage female: 35%
  • Percentage with diabetes: 45%

Inclusion criteria:

Subjects with nonvalvular atrial fibrillation and one of the following:

  • Bleeding requiring hospitalization or intervention
  • History of cardioembolic event while on anticoagulation
  • CHA2DS2-VASc score ≥3
  • HAS-BLED score ≥2

Exclusion criteria:

  • Mechanical heart valve or mitral stenosis
  • Alternative reason for anticoagulation
  • Patent foramen ovale with large atrial septal aneurysm
  • Mobile aortic plaque
  • Symptomatic carotid disease
  • Pericardial effusion
  • Clinically significant bleeding within the last 30 days
  • Acute coronary syndrome within the last 90 days
  • Creatine clearance <30 cc/min
  • Left atrial appendage thrombus

Other salient features/characteristics:

  • Mean CHA2DS2-VASc score: 4.7
  • Mean HAS-BLED score: 3.0
  • In the left atrial appendage occlusion group, 5.6% were withdrawn because of lack of informed consent or left atrial appendage thrombus. In an additional 9.4%, the procedure was unsuccessful and these patients crossed over to a NOAC.

Principal Findings:

The primary net outcome of cardiovascular death, stroke/transient ischemic attack, systemic embolism, clinically significant bleeding (ISTH major or nonmajor clinically significant bleeding), or significant procedure/device-related complication was similar between the two treatment groups (hazard ratio [HR] 0.84, p for noninferiority = 0.004).

For secondary outcomes: Major or nonmajor clinically significant bleeding was similar between the two treatment groups (HR 0.81, p = not significant).


Among patients with nonvalvular atrial fibrillation, left atrial appendage occlusion was noninferior to a NOAC (apixaban) at preventing net ischemic/bleeding events. Many questions remain regarding proper selection of patients and best practice for this technology.


Osmancik P, Herman D, Neuzil P, et al. Left Atrial Appendage Closure Versus Direct Oral Anticoagulants in High-Risk Patients With Atrial Fibrillation. J Am Coll Cardiol 2020;75:3122-35.

Editorial Comment: Price MJ, Saw J. Transcatheter Left Atrial Appendage Occlusion in the DOAC Era. J Am Coll Cardiol 2020;75:3136-9.

Presented by Dr. Pavel Osmancik at the European Society of Cardiology Congress, Paris, France, September 2, 2019.

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Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Noninvasive Imaging, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound

Keywords: ESC Congress, Anticoagulants, Arrhythmias, Cardiac, Aspirin, Atrial Appendage, Atrial Fibrillation, Coronary Occlusion, Echocardiography, Transesophageal, Embolism, Hemorrhage, Ischemic Attack, Transient, Myocardial Ischemia, Secondary Prevention, Stroke, Thrombosis, ESC 19

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