Left Atrial Appendage Closure: An Alternative to Anticoagulation for Stroke Prevention in Patients with Kidney Disease

Vallurupalli, Srikanth; Sharma, Tanya; Al’Aref, Subhi J.; Devabhaktuni, Subodh; Dhar, Gaurav

doi:10.34067/kid.0004082021

Cited by 6 publications

(3 citation statements)

References 30 publications

(41 reference statements)

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“…LAA closure (LAAC) is routinely performed via a venous transcatheter femoral access. A self-expanding device with a polymer membrane is delivered in the LAA throughout a trans-septal puncture in order to exclude the LAA cavity from the rest of the atrium, thereby obliterating the site that is the nidus for thrombus formation ( 111 ).…”

Section: Discussionmentioning

confidence: 99%

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Lucà

Colivicchi

Oliva

et al. 2023

Front. Cardiovasc. Med.

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Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.

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Section: Discussionmentioning

confidence: 99%

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Lucà

Colivicchi

Oliva

et al. 2023

Front. Cardiovasc. Med.

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“…Two RCTs designed to evaluate the safety (primary outcome: first episode of major bleeding) of LAAC versus VKAs in patients with an estimated GFR (eGFR) <30 ml/min/1.73 m 2 (CKD G4, G5 and G5D) were terminated prematurely due to lack of recruitment [Watch-AFIB (NCT02039167) and STOP-ARM (NCT02885545)] [ 80 ]. A third RCT including only patients with an eGFR <15 ml/min/1.73 m 2 and comparing LAAC with best medical care, with a primary composite outcome of first stroke, systemic embolism, cardiovascular or unexplained death or major bleeding, is ongoing [LAA-Kidney trial (NCT05204212)].…”

Section: New Developmentsmentioning

confidence: 99%

Treatment strategies of the thromboembolic risk in kidney failure patients with atrial fibrillation

Genovesi,

Camm,

Covic

et al. 2024

Nephrology Dialysis Transplantation

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The incidence and prevalence of atrial fibrillation (AF) in patients affected by kidney failure, i.e. glomerular filtration rate <15 ml/min/1.73 m2, is high and probably underestimated. Numerous uncertainties remain regarding how to prevent thromboembolic events in this population because both cardiology and nephrology guidelines do not provide clear recommendations. The efficacy and safety of oral anticoagulant therapy (OAC) in preventing thromboembolism in patients with kidney failure and AF has not been demonstrated for either vitamin K antagonists (VKAs) or direct anticoagulants (DOACs). Moreover, it remains unclear which is more effective and safer, because estimated creatinine clearance <25–30 ml/min was an exclusion criterion in the randomized controlled trials (RCTs). Three RCTs comparing DOACs and VKAs in kidney failure failed to reach the primary endpoint, as they were underpowered. The left atrial appendage is the main source of thromboembolism in the presence of AF. Left atrial appendage closure (LAAC) has recently been proposed as an alternative to OAC. RCTs comparing the efficacy and safety of LAAC versus OAC in kidney failure were terminated prematurely due to recruitment failure. A recent prospective study showed a reduction in thromboembolic events in haemodialysis patients with AF and undergoing LAAC compared with patients taking or not taking OAC. We review current treatment standards and discuss recent developments in managing the thromboembolic risk in kidney failure patients with AF. The importance of shared decision-making with the multidisciplinary team and the patient to consider individual risks and benefits of each treatment option is underlined.

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“…There is recent interest in applying LAA occlusion in patients with ESRD. 78 But the current data on safety and efficacy are limited to 5 small studies with a total of 84 patients. 78 It is too early to recommend LAA occlusion as an effective alternative therapy for patients with ESRD.…”

Section: Nonpharmacologic Managementmentioning

confidence: 99%

Stroke Prevention in Atrial Fibrillation

Chiang

Chao²,

Choi³

et al. 2022

JACC: Asia

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Left Atrial Appendage Closure: An Alternative to Anticoagulation for Stroke Prevention in Patients with Kidney Disease

Cited by 6 publications

References 30 publications

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Treatment strategies of the thromboembolic risk in kidney failure patients with atrial fibrillation

Stroke Prevention in Atrial Fibrillation

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