Left atrial appendage occlusion after thromboembolic events or left atrial appendage sludge during anticoagulation therapy: Is two better than one? Real‐world experience from a tertiary care hospital

Abstract

Background:The role of left atrial appendage occlusion (LAAO) for atrial fibrillation patients that during oral anticoagulant therapy (OAC) suffer from ischemic events or present LAA sludge, and the best postinterventional anticoagulant regimen, need to be defined. We present our experience with a hybrid approach of LAAO+ lifelong OAC therapy in this cohort of patients.Methods: Out of 425 patients treated with LAAO, 102 underwent LAAO because, despite OAC, suffered from ischemic events or presented with LAA sludge. Patients without high bleeding risk were discharged with the aim of maintaining lifelong OAC.This cohort was then matched to a population who underwent LAAO in primary ischemic events prevention. The primary endpoint was the composite of all-cause death and major adverse cardiovascular events consisting of ischemic stroke, systemic embolism (SE), and major bleeding.Results: Procedural success was 98%, and 70% of patients were discharged with anticoagulant therapy. After a median follow-up of 47.2 months, the primary endpoint occurred in 27 patients (26%). At multivariate analyses, coronary artery disease (OR 5.1, CI 1.89-14.27, p = .003) and OAC at discharge (OR 0.29, CI 0.11-0.80, p = .017) were associated with the primary endpoint. After propensity score matching, no significant difference was found in the survival free from the primary endpoint according to the indication for LAAO (p = .19). Conclusions:In this high-ischemic risk cohort, LAAO + OAC seem a long-term safe and effective therapeutical approach, with no difference in the survival free from the primary endpoint according to the indication for LAAO in a matched cohort.

Left atrial appendage thrombus formation despite oral anticoagulation: what can we do when there is nothing to offer?

“…Recently, a beneficial synergistic effect of continuing OAC plus LAA occlusion in high-risk patients without contraindications for anticoagulation in reducing systemic and cerebral embolic events, as well as allcause mortality, has been proposed (4, 24, 51, 52). In our series, the presence of DRT was not detected during follow-up; its incidence has been reported to be 1.5 -14% (20,24,53,54). Margonatto et al (24), reported 13% of DRT in their patients, occurred in those who had been discharged under dual antiplatelet therapy, and it resolved when switching to OAC.…”

“…In our series, the presence of DRT was not detected during follow-up; its incidence has been reported to be 1.5 -14% (20,24,53,54). Margonatto et al (24), reported 13% of DRT in their patients, occurred in those who had been discharged under dual antiplatelet therapy, and it resolved when switching to OAC.…”

“…Those that protrude from the ostium into the atrial cavity were considered a contraindication for direct percutaneous closure (20). Double closure devices, Plug/Umbrella + disc, were the most used, between 75-85% for the Amulet, ACP and Lambre group vs 15-25% for Watchman (specifically Watchman Flex) (18,20,24,25,31,50). Recently, a beneficial synergistic effect of continuing OAC plus LAA occlusion in high-risk patients without contraindications for anticoagulation in reducing systemic and cerebral embolic events, as well as allcause mortality, has been proposed (4, 24, 51, 52).…”

Left Atrial Appendage Closure in Patients With Mechanical Mitral Valve Prosthesis: A Multicenter Italian Pilot Study

“…A call for therapeutic alternatives in patients with "valvular AF" and OAC failure LAAC in patients with AF and failure of OAC therapy is a continually expanding indication due to proved safety and efficacy of the procedure and no need for antithrombotic therapy enhancement [18,19]. However, all LAAC devices that have acquired commercial approvement so far were tested only in the specific population affected by non valvular AF and anticoagulant contraindication.…”

Fighting Cardiac Thromboembolism during Transcatheter Procedures: An Update on the Use of Cerebral Protection Devices in Cath Labs and EP Labs

“…In recent years, some retrospective studies [ 24 ] and one multicenter registry [ 76 ] highlighted the feasibility and safety of this procedure using Amulet (St. Jude Medical) and Watchman (Boston Scientific) devices. In a study, LAAC was proposed in combination with OAC as an enhancement of antithrombotic therapy in AF patients incurred in stroke/systemic embolism despite OAC, reporting optimistic results in terms of feasibility and safety after 5 years of follow-up [ 77 ]. The use of CPD in this scenario may further reduce the risk of severe intraprocedural complications.…”