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Antithrombotic Therapy After Left Atrial Appendage Occlusion
Quick Takes
- Several different antithrombotic strategies have been tested for patients undergoing LAAO for AF.
- DOAC monotherapy was associated with lower risk of device thrombosis and all-cause mortality than no antithrombotic therapy.
- For patients not at excessive bleeding risk, DOAC monotherapy is likely the optimal antithrombotic therapy after LAAO, balancing bleeding and thromboembolism risk.
Study Questions:
What is the efficacy and safety of various antithrombotic strategies after left atrial appendage occlusion (LAAO)?
Methods:
The authors performed a systematic review and network meta-analysis of outcomes after LAAO, stratified by antithrombotic therapies. Direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), DOAC plus SAPT, VKA plus SAPT, and no antithrombotic therapy were all assessed. The primary efficacy outcome was device-related thrombosis, as seen on transesophageal echocardiogram or computed tomography (CT) scan. The primary safety endpoint was major bleeding, as defined by the Bleeding Academic Research Consortium (BARC) or Valve Academic Research Consortium-2 (VARC-2).
Results:
Forty studies of 11,111 patients with nonvalvular atrial fibrillation (AF) were included in the analysis. As compared to no antithrombotic therapy, DAPT (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.16-0.76), DOAC (OR, 0.35; 95% CI, 0.13-0.94), DOAC plus SAPT (OR, 0.17; 95% CI, 0.04-0.74), and VKA therapy (OR, 0.34; 95% CI, 0.12-0.97) were superior for the efficacy outcome of device-related thrombosis. DOAC therapy was superior to VKA for the outcome of all-cause mortality (OR, 0.36; 95% CI, 0.15-0.85). DAPT was superior to SAPT for reducing thromboembolic events (OR, 0.49; 95% CI, 0.26-0.91). There was not a statistically significant difference in major bleeding between any antithrombotic regimen comparison.
Conclusions:
The authors concluded that in patients with nonvalvular AF undergoing LAAO, DOAC plus SAPT and DOAC monotherapy are the most effective at reducing device-related thrombosis complications without significant increases in bleeding risk as compared to other antithrombotic regimens.
Perspective:
In patients with nonvalvular AF undergoing LAAO, there has been continued evolution in the antithrombotic strategy used to prevent device-related thrombosis while avoiding bleeding complications. Initially using VKA therapy, more recent studies have suggested DOAC therapy and DAPT or SAPT therapy can be considered. This is important as many patients being evaluated for LAAO are at high risk of medication-related bleeding. This network meta-analysis suggests that DOAC therapy likely offers the best balance between efficacy and safety for most patients with nonvalvular AF undergoing LAAO. However, when DOAC therapy is not feasible (e.g., patient with DOAC-related bleeding), this study also supports the use of DAPT. However, it is not clear that switching from DOAC therapy to DAPT or SAPT will necessarily reduce bleeding risk following LAAO placement.
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, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Coronary Occlusion, Echocardiography, Transesophageal, ESC Congress, ESC23, Fibrinolytic Agents, Hemorrhage, Platelet Aggregation Inhibitors, Risk, Secondary Prevention, Thromboembolism, Thrombosis, Tomography, X-Ray Computed, Vascular Diseases, Vitamin K
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