Left atrial appendage closure: A therapy uniquely suited for specific populations of patients with atrial fibrillation

Abstract

Atrial fibrillation (AF) is the most common clinically relevant arrhythmia and confers a fivefold increased risk for stroke. Cardioembolic stroke secondary to AF is a devastating event, but is largely preventable with appropriate oral anticoagulation (OAC). The PROTECT and PREVAIL trials demonstrated that the WATCHMAN left atrial appendage closure (LAAC) device in combination with short‐term warfarin therapy is noninferior to long‐term warfarin with respect to a composite endpoint of stroke, cardiovascular death, and systemic embolism. Importantly, the WATCHMAN confers a significant reduction in life‐threatening bleeding compared to OAC. Although direct‐acting oral anticoagulant (DOAC) are superior to warfarin in eligible patients, several important AF populations exist in whom left atrial appendage (LAA) closure may be preferable to DOAC. Populations warranting strong consideration of LAAC include patients with contraindications to DOAC, end‐stage renal disease, prior intracranial hemorrhage, recurrent gastrointestinal bleeding, and patients undergoing transcatheter aortic valve replacement or left atrial electrical isolation. Device‐related thrombosis is an important complication of LAAC, and DOAC may be preferential to warfarin for prevention and treatment of this complication remains unexplored. Prospective clinical trials comparing DOAC to LAAC in these unique populations are either ongoing or needed.

Efficacy and safety of left atrial appendage occlusion in atrial fibrillation patients with chronic kidney disease: a systematic review and meta-analysis

“…Such patients consistently exhibit low rates of stroke and major bleeding events. Therefore, LAAO is suitable for patients contraindicated for oral anticoagulants, end-stage renal disease, recurrent gastrointestinal hemorrhage, and prior intracranial hemorrhage (Black-Maier et al, 2019). Here, we performed a meta-analysis to determine the efficacy and safety of LAAO in CKD patients with AF.…”

Left Atrial Appendage Closure for Atrial Fibrillation in the Elderly >75 Years Old: A Meta-Analysis of Observational Studies

“…Our study consisted mainly of patients with LAAC before 2018. With the increase in the number of LAAC, the likelihood of adverse events occurring during the perioperative period normally decreases, even in elderly patients [ 34 ].…”

Influence of Prior Major Bleeding on the Safety and Effectiveness of Left Atrial Appendage Closure in Non-Valvular Atrial Fibrillation Patients: A Single-Center Study

“…Regarding the e cacy of LAAC in AF patients who had a prior bleeding, there were several small sample studies which reported the effectiveness and safety of LAAC [31][32][33][34]; however, none of them focused on comparing the difference in e cacy of LAAC between patients with and without prior bleeding. Our study compared the extent of RRR in thromboembolic events and major bleeding attributed to LAAC strategy between patients with and without a history of prior bleeding.…”