Low Dose of Direct Oral Anticoagulants after Left Atrial Appendage Occlusion

Abstract

The optimal antithrombotic strategy following left atrial appendage occlusion (LAAO) is not yet clearly established. Low-dose non-vitamin K antagonist oral anticoagulants (NOAC) might represent a valid alternative, but data regarding their usage is scarce. The aim of this study was to examine the efficacy and safety of low-dose NOAC compared to single (SAPT) or dual antiplatelet therapies (DAPT) after LAAO. We included consecutive patients with non-valvular atrial fibrillation who underwent LAAO and received low-dose apixaban, SAPT, or DAPT at discharge. The primary objective of this study included an efficacy endpoint (thromboembolic events and device related thrombosis (DRT)) and a safety endpoint (incidence of major bleeding) within the first three months after LAAO. A total of 139 patients were included. This group involved SAPT in 26 (18%), DAPT in 73 (53%), and apixaban in 40 (29%) patients. Follow-up at three-months showed no significant differences in the primary efficacy endpoint (2 (8%) SAPT, 3 (4%) DAPT and 0 (0%) apixaban; p value = 0.25). In contrast, the primary safety endpoint occurred more frequently in DAPT patients (7 (10%) DAPT, 0 (0%), SAPT and 0 with apixaban; p value = 0.03). Combining both efficacy and safety outcomes, low dose apixaban had a lower rate of events (2 (8%) with SAPT, 9 (12%) with DAPT and 0 (0%) with apixaban; p = 0.046). Low-dose apixaban after LAAO may be a valid alternative to DAPT and SAPT as depicted by the reduction in the occurrence of major bleedings and combined DRT/major bleedings respectively. Randomized data will be necessary to validate this strategy.

Percutaneous Left Atrial Appendage Closure With a Novel LAA Occluder for Stroke Prevention in Atrial Fibrillation

“…Actually, there are many other factors that affect the efficacy of LAA closure, including antithrombotic therapy. 25 , 26 As there have been no randomized controlled trials of antithrombotic therapy in LAA closure, this must be further investigated.…”

Treatment of Persistent Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation on Adequate Oral Anticoagulation: Pathways of Care for All-comers and Heart Failure Patients

“…60 Cepas-Guillen et al recently conducted a study in which a low-dose strategy with apixaban (2.5 mg twice daily) was tested against single antiplatelet therapy (SAPT; low-dose aspirin 100 mg once daily) and DAPT (aspirin 100 mg + clopidogrel 75 mg once daily) in patients with nonvalvular AF who underwent LAAO. 61 The authors concluded that a strategy with low-dose apixaban following LAAO might be a feasible and effective alternative to DAPT and SAPT concerning combined efficacy and safety endpoints. However, this study was not randomised and enrolled a limited number of patients.…”

Left atrial appendage occlusion

“…Data from a small RCT also reported a numerically lower rate of DRT with DOAC (0%) compared to DAPT (6%) 65 . Of note, preliminary data suggested that low-(versus full-) dose DOAC could result in the same beneficial effects regarding DRT and thromboembolic protection after LAAO 75,78 . Multiple randomised trials are comparing DOAC versus DAPT following LAAO and will likely provide more definite data on the safety and efficacy of this therapy (Table 9).…”

“…This therapy has recently been considered as a potential alternative following LAAO in patients e 1056 eligible for short-term OAC. Data from several observational studies have shown extremely low rates of DRT (0 to 1.3%, 0% in the majority of studies), and thromboembolic events in patients treated with DOAC following LAAO 23,64,65,[73][74][75][76][77][78] . Furthermore, some studies have also suggested a lower rate of bleeding events among DOAC patients compared to their DAPT counterparts 73,75 .…”