Left Atrial Appendage Occlusion vs. DOAC in Atrial Fibrillation

Jan 13, 2021
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Authors:
Neilsen-Kudsk JE, Korsholm K, Damgaard D, et al.
Citation:
Clinical Outcomes Associated With Left Atrial Appendage Occlusion Versus Direct Oral Anticoagulation in Atrial Fibrillation. JACC Cardiovasc Interv 2021;14:69-78.
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Quick Takes

  • Use of LAAO is associated with a reduced combined risk of ischemic stroke, major bleeding, and all-cause death as compared to DOACs for patients with AF.
  • LAAO is associated with similar ischemic stroke risk as DOAC therapy for high-risk patients with AF.
  • LAAO is associated with lower rates of ischemic stroke and all-cause mortality than DOAC therapy for high-risk patients with AF.

Study Questions:

What are the clinical outcomes associated with left atrial appendage occlusion (LAAO) versus direct oral anticoagulant (DOAC) therapy for patients with high-risk atrial fibrillation (AF)?

Methods:

Patients with AF were enrolled in the Amulet Observational Registry who had successful LAAO placement with the Amplatzer Amulet device. They were compared to propensity score-matched patients with incident AF treated with DOAC therapy in the Danish national patient registries. Matching was based on stroke and bleeding risk factors. The primary outcome was a composite of ischemic stroke, Bleeding Academic Research Consortium (BARC) major bleeding, or all-cause mortality. Follow-up was for 2 years.

Results:

The 1,078 patients treated with LAAO experienced a lower risk of the primary composite outcome as compared to the 1,184 matched patients treated with DOAC therapy (14.5 vs. 25.7 events/100 patient-years; hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.49-0.67). The risk of ischemic stroke was similar in the two groups (HR, 1.11; 95% CI, 0.71-1.75), while the risk of major bleeding (HR, 0.62; 95% CI, 0.49-0.79) and all-cause mortality (HR, 0.53; 95% CI, 0.43-0.64) was lower for the patients treated with LAAO.

Conclusions:

The authors concluded that among high-risk patients with AF, use of LAAO reduced the risk of major bleeding and all-cause mortality while having similar risk of ischemic stroke as compared to DOAC therapy.

Perspective:

This observational study confirms the relative efficacy and safety of LAAO for patients with AF who are at high risk for stroke. While this comparison is helpful, it must be acknowledged that patients with AF who receive LAAO are often different from those treated with DOAC. Largely this related to bleeding risk, which cannot be completely estimated using common bleeding risk scores (e.g., HAS-BLED). Nonetheless, the results should provide reassurance that if a patient with AF is at high risk for both stroke and bleeding complications, LAAO is a reasonable alternative to DOAC therapy.

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

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Brain Ischemia, Coronary Occlusion, Hemorrhage, Ischemia, Risk Factors, Secondary Prevention, Stroke, Vascular Diseases


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