Looking for optimal antithrombotic strategy after transcatheter left atrial appendage occlusion: a real-world comparison of different antiplatelet regimens

Vignali, Luigi; Gurgoglione, Filippo Luca; Barocelli, Federico; Cattabiani, Maria Alberta; Solinas, Emilia; Maini, Arianna; Tadonio, Iacopo; Benatti, Giorgio; Pelà, Giovanna; Coli, Stefano; Ardissino, Diego; Niccoli, Giampaolo

doi:10.1016/j.ijcard.2022.09.066

Cited by 9 publications

(9 citation statements)

References 48 publications

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“…Due to these challenges reducing or shortening anti-thrombotic strategies medication is being tested more widely. 10,[13][14][15][18][19][20] These studies endorse the safety and efficacy of our proposition.…”

Section: Randomized Controlled Trials Have Shown That Laao Withsupporting

confidence: 71%

“…Many centers will only offer LAAO to those that are deemed safe to take a period of postprocedural anti‐thrombotic agents making the therapy unavailable to those that may potentially benefit the most. Due to these challenges reducing or shortening anti‐thrombotic strategies medication is being tested more widely 10,13–15,18–20 . These studies endorse the safety and efficacy of our proposition.…”

Section: Discussionmentioning

confidence: 66%

“…This may also explain the high bleeding rates in the postimplant period of the PRAGUE‐17 trial 7 . Other non‐randomized series implanting LAAO in patients with high‐risk of bleeding with long term anticoagulation have also used dual antiplatelets or single antiplatelets in the postoperative period 10–15 . The multicenter Amulet Registry is one of the largest series and had a similar rate of bleeding to PRAGUE‐17 16 .…”

Section: Discussionmentioning

confidence: 99%

“…7 Other non-randomized series implanting LAAO in patients with high-risk of bleeding with long term anticoagulation have also used dual antiplatelets or single antiplatelets in the postoperative period. [10][11][12][13][14][15] The multicenter Amulet Registry is one of the largest series and had a similar rate of bleeding to PRAGUE-17. 16 A single center series with a higher proportion of patients with prior bleeds, used a shorter period of dual antiplatelets had a lower bleeding rate but a higher ischemic stroke rate.…”

Section: Randomized Controlled Trials Have Shown That Laao Withmentioning

confidence: 99%

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Left atrial appendage occlusion for atrial fibrillation and bleeding diathesis

Kailey,

Koa‐Wing,

Sutaria

et al. 2023

Cardiovasc electrophysiol

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BackgroundPatients with atrial fibrillation (AF) and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. Short‐term anti‐thrombotic drugs are used postprocedure to offset the risk of device‐related thrombus, evidence for this practice is limited.ObjectivesTo investigate optimal postimplant antithrombotic strategy in high bleeding‐risk patients.MethodsPatients with AF and high‐risk for both stroke and bleeding undergoing LAAO were advised their perioperative drug therapy by a multidisciplinary physician panel. Those deemed to be at higher risk of bleeding from anti‐thrombotic drugs were assigned to minimal treatment with no antithrombotics or Aspirin‐alone. The remaining patients received standard care (STG) with a 12 week course of dual‐antiplatelets or anticoagulation postimplant. We compared mortality, device‐related thrombus, ischemic stroke, and bleeding events during the 90 days postimplant and long‐term. Event‐free survival was assessed using Kaplan−Meier survival analysis, with logrank testing for statistical significance.ResultsSeventy‐five patients underwent LAAO of whom 63 patients (84%) had a prior serious bleeding event. The 42 patients on minimal treatment were older (74.3 ± 7.7 vs. 71.2 ± 7.2) with higher HASBLED score (3.6 ± 0.9 vs. 3.3 ± 1.2) than the 33 patients having standard care. There were no device‐related thrombi or strokes in either group at 90 days postprocedure; STG had more bleeding events (5/33 vs. 0/42, p = 0.01) with associated deaths (3/33 vs. 0/42, p = 0.05). During long‐term follow‐up (median 2.2 years), all patients transitioned onto no antithrombotic drugs (43 patients [61%]) or a single‐antiplatelet (29 patients [39%]). There was no evidence of early minimal treatment adversely affecting long‐term outcomes.ConclusionsShort‐term anti‐thrombotic drugs may not be needed after LAAO implant in patients with high bleeding risk and could be harmful. Larger, prospective studies would be warranted to test these findings.

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Section: Randomized Controlled Trials Have Shown That Laao Withsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 66%

Section: Discussionmentioning

confidence: 99%

Section: Randomized Controlled Trials Have Shown That Laao Withmentioning

confidence: 99%

See 2 more Smart Citations

Left atrial appendage occlusion for atrial fibrillation and bleeding diathesis

Kailey,

Koa‐Wing,

Sutaria

et al. 2023

Cardiovasc electrophysiol

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“…Two days after the procedure, weighing the patient’s individual risk for bleeding and thromboembolism, patient was discharged on dual antiplatelet therapy (aspirin plus clopidogrel) for 1 month, followed by clopidogrel up to 6 months. 10 No adverse ischaemic and haemorrhagic events occurred at 3-months follow-up.…”

Section: Case Presentationmentioning

confidence: 89%

A giant left atrial appendage: a case report on the feasibility of closure with a custom-made device

Barocelli,

Gurgoglione,

Covani

et al. 2023

European Heart Journal - Case Reports

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Background Transcatheter left atrial appendage occlusion (LAAO) is a valuable therapeutic option for stroke prevention in patients with atrial fibrillation (AF) at high bleeding risk. However, complex LAA anatomies sometimes preclude the adoption of commercially available LAAO devices. The design of a custom-made LAAO device is a promising strategy in these cases. However, few examples of custom-made devices in case of giant LAAs have been reported. Case summary An 85-year-old man with permanent AF with CHA2DS2-VASc 4 and recurrent active gastrointestinal major bleedings was referred for transcatheter LAAO at Parma University Hospital after multidisciplinary team evaluation. Pre-procedural coronary computed tomography angiography revealed a giant windsock LAA, with a maximum ostium diameter of 44 mm, a landing zone diameter of 34 mm, and maximal length of 49 mm. Patient’s management was particularly challenging given that available LAAO devices were too small to completely exclude the LAA. In accordance with the manufacturer, a custom-made LAmbre™ Closure System (Lifetech Scientific, Shenzhen, China), which specifically fitted with patient’s LAA anatomy, was designed and successfully deployed under transoesophageal echocardiography (TEE) and fluoroscopic guidance. Periprocedural TEE confirmed the appropriate position of the device and the absence of peri-device leaks. No adverse ischaemic and haemorrhagic events were reported at 3-months follow-up. Discussion We present a case of a successful transcatheter LAAO procedure by deploying a custom-made LAmbre device 38/46 mm to mechanically exclude a giant windsock LAA. This case illustrates the effectiveness of a custom-made device strategy, which potentially enables the closure of all complex LAA anatomies.

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