Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study

Casu, Gavino; D’Angelo, Giuseppe; Ugo, Fabrizio; Ronco, Federico; Simonetto, Federico; Barbierato, Marco; Magni, Valeria; Boccuzzi, Giacomo; Margonato, Alberto; Moroni, Francesco; Delitala, Alessandro; Lorenzoni, Giovanni; Beneduce, Alessandro; Rametta, Francesco; Mazzone, Patrizio; Bella, Paolo Della; Montorfano, Matteo; Merella, Pierluigi

doi:10.1016/j.ijcard.2020.11.045

Cited by 17 publications

(12 citation statements)

References 37 publications

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“…Besides anticoagulant treatment, another available and radical approach for AF patients after ICH management is LAA occlusion. In several national observational studies and RCTs (PROTECT AF and PREVAIL), it was demonstrated that, compared with VKA treatment, the LAA occlusion was non-inferior to preventing stroke and major bleeding (35)(36)(37). The LAA occlusion is a potential alternative approach for patients with AF who are contraindicated to anticoagulant treatment.…”

Section: Discussionmentioning

confidence: 99%

Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

Liu

Guo

2022

Front. Cardiovasc. Med.

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BackgroundIntracranial hemorrhage (ICH) is excluded in most anticoagulation randomized clinical trials (RCTs), so oral anticoagulant (OAC) therapy is still the conventional treatment for patients with atrial fibrillation (AF) after ICH. Therefore, we conducted a meta-analysis to determine the effectiveness and safety outcomes of OAC for these patients.MethodsWe systematically searched the PubMed and Embase databases up to March 2022 for RCTs and observational studies exploring the effect of OAC in patients with AF after ICH. The effectiveness outcomes included stroke or systemic embolism, ischemic stroke, and all-cause death, whereas the safety outcomes were major bleeding and recurrent ICH. Hazard ratios (HRs) and 95% confidence intervals (CIs) from each study were pooled using a random-effects model.ResultsA total of 14 studies were included. The OAC therapy that was performed reduced the risks of stroke or systemic embolism (HR = 0.65, 95% CI 0.53–0.81), ischemic stroke (HR = 0.70, 95% CI 0.60–0.82), and all-cause death (HR = 0.43, 95% CI 0.27–0.70) but had a higher risk of major bleeding (HR = 1.50, 95% CI 0.94–2.40) and showed no difference in recurrent ICH (HR = 0.91, 95% CI 0.53–1.55) compared to the no OAC therapy. With the use of non-vitamin K antagonist oral anticoagulant (NOAC) therapy, a lower risk of stroke or systemic embolism (HR = 0.83, 95% CI 0.70–0.98), all-cause death (HR = 0.67, 95% CI 0.53–0.84), and recurrent ICH (HR = 0.68, 95% CI 0.54–0.86) was observed against the use of vitamin K antagonists (VKA) therapy.ConclusionThe OAC therapy (especially VKA) revealed superior effectiveness in patients with AF after ICH, and the superiority of NOAC was also found, but some related evidence was limited.

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Section: Discussionmentioning

confidence: 99%

Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

Liu

Guo

2022

Front. Cardiovasc. Med.

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“…Despite the lack of RCTs on LAAC in patients with previous ICH, there is every likelihood that LAA occlusion could be a beneficial option in these patients (122)(123)(124)(125)(126)(127). LAAC could represent the only alternative in patients with an absolute contraindication to OACs.…”

Section: Non-pharmacologic Options (Percutaneous Left Atrial Appendag...mentioning

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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“…Given this risk, anticoagulation is a standard component of postoperative treatment for cardiac surgery patients. However, the use of anticoagulants and antiplatelet agents carries an increased risk of hemorrhage and other side effects, especially in frail and elderly populations [10].…”

Section: Introductionmentioning

confidence: 99%

Prophylactic Left Atrial Appendage Ligation During Coronary Artery Bypass Graft Surgery Allows Safe Avoidance of Anticoagulation Regardless of Postoperative Atrial Fibrillation

Khalpey,

Aslam,

Wilson

et al. 2024

Cureus

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BackgroundNew-onset postoperative atrial fibrillation (POAF) is the most common arrhythmia following cardiac surgery. POAF increases the risk of thromboembolism and stroke, as well as morbidity and mortality more generally. Despite evidence from the landmark PROTECT-AF and PREVAIL trials, left atrial appendage ligation (LAAL) is not routinely performed for thromboembolism prophylaxis in POAF, and anticoagulation remains the standard of care along with dual antiplatelet therapy. This study evaluated the efficacy of concomitant LAAL in eliminating the need for postoperative anticoagulation, regardless of POAF development, in patients undergoing coronary artery bypass grafting (CABG). MethodsBetween 2019 and 2021, 130 patients were selected to undergo concomitant LAAL while undergoing CABG surgery. Patients were then monitored for the incidence of new-onset POAF, and anticoagulation was strictly avoided for this indication. Demographic and outcome data were collected, with endpoints including transient ischemic attack (TIA) or stroke, death, and readmission within one year, as well as the length of hospital and intensive care unit (ICU) admissions. ResultsPOAF occurred in 37 patients (28.5%), consistent with previous reports. However, none of the POAF patients experienced TIA or stroke during the one-year follow-up period, compared to 2 (2.15%) in the non-POAF group, a typical rate of postoperative stroke in such a patient population. No significant differences were observed between POAF and non-POAF cohorts in one-year stroke, all-cause mortality, readmission rates, or total hospital stay. Interestingly, the POAF cohort had a significantly longer mean ICU stay (4.24 vs 3.37 days, p = 0.0219), possibly due to the time required for arrhythmia control before discharge. The study population had a high mean CHA 2 DS 2 -VASc score (2.81), indicating an increased risk of thromboembolism, and a high mean HAS-BLED score, suggesting an elevated bleeding risk with anticoagulation. ConclusionsLAAL appears to be an effective adjunct to CABG for thromboembolism prophylaxis in POAF. Formal anticoagulation was avoided in this study, with no significant differences in adverse events between POAF and non-POAF groups, suggesting that LAAL may be a suitable alternative to anticoagulation, especially in high-risk patients (e.g., those with elevated CHA 2 DS 2 -VASc or HAS-BLED scores). The safety and efficacy of this approach should be corroborated by larger randomized studies, such as the ongoing LeAAPS trial. LAAL during CABG may help reduce the risk of bleeding complications associated with anticoagulation while maintaining protection against thromboembolic events in patients who develop POAF.

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Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study

Cited by 17 publications

References 37 publications

Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage

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

Prophylactic Left Atrial Appendage Ligation During Coronary Artery Bypass Graft Surgery Allows Safe Avoidance of Anticoagulation Regardless of Postoperative Atrial Fibrillation

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