The Impact of Dabigatran and Rivaroxaban on Variation of Platelet Activation Biomarkers and DRT Following Percutaneous Left Atrial Appendage Closure

Abstract

Background: The current post-procedure antithrombotic recommendation for left atrial appendage closure (LAAC) remains empiric. This study was designed to compare variations in platelet activation biomarkers and device-related thrombosis (DRT) under different antithrombotic regimens following LAAC.Methods: This study enrolled 105 consecutive patients with atrial fibrillation who underwent LAAC successfully and received post-procedure anticoagulation with either dabigatran (N = 33) or rivaroxaban (N = 72). After 3 months of anticoagulation treatment, thromboelastogram was used to evaluate thrombin receptor–activating peptide (TRAP)–induced platelet aggregation (PA). Measurements of platelet activation biomarkers, including thrombin–antithrombin complex (TAT), P-selectin, von Willebrand disease (vWF), and CD40L, were performed immediately before the LAAC procedure and after 3 months of post-procedure anticoagulation. Repeated transesophageal echocardiography was performed to evaluate DRT during follow-ups.Results: Three (4.2%) patients in the rivaroxaban and 4 (12.1%) patients in the dabigatran group experienced DRT events (odds ratio (OR) = 0.315, 95% confidence interval (95%CI): 0.066–1.489, p = 0.129) during follow-ups. The TRAP-induced PA was statistically significantly higher in the dabigatran group (62.9% vs 59.7%, p = 0.028*). Statistically significant increases in plasma concentration of TAT, P-selectin, and vWF were observed after 3 months of exposure to dabigatran when compared with rivaroxaban. An increased expression of platelet activation biomarkers was observed in DRT subjects compared with non–DRT subjects in terms of P-selectin and vWF (65.28 ± 13.93 ng/L vs 32.14 ± 12.11 ng/L, p = 0.037; 501.92 ± 106.48 U/L vs 280.98 ± 54.10 U/L, p = 0.045; respectively). Multivariate regression analysis indicated that the use of dabigatran might be an independent predictor of DRT (p = 0.022; OR = 4.366, 95%CI: 0.434–10.839). Furthermore, the CHA2DS2-VASc score (OR = 2.076, p = 0.016) and CD40L levels (OR = 1.015, p = 0.021) were independent predictors of increased D-dimer levels.Conclusions: Post-LAAC anticoagulation with dabigatran may increase the risk of DRT by enhancing platelet reactivity. In light of this potential increased risk in DRT, the authors recommend against using dabigatran for post-procedural anticoagulation in patients who have undergone LAAC.

Perioperative Treatment with Rivaroxaban and Dabigatran on Changes of Coagulation and Platelet Activation Biomarkers following Left Atrial Appendage Closure

“…In terms of primary endpoints related to stroke or SE events, our study did not reveal a significant difference between the two anticoagulation strategies. However, it is noteworthy that patients medicated with rivaroxaban exhibited lower rates of SE when compared to those taking dabigatran, in line with previous research findings [ 21 ]. To provide context, the ROCKET-AF trial reported a stroke or SE incidence of 1.7% per year [ 22 ].…”

“…Conversely, elevated platelet reactivity is determined in dabigatran therapy, mainly by enhancing the thrombin receptor density on platelet [35]. These in vivo observations have been recently corroborated by prospective clinical studies, providing further insights into coagulation changes after a successful LAAC operation with different antithrombotic regimens [21,34]. One previous study illustrated that rivaroxaban might potentially prevent periprocedural DRT and thrombus events as compared to dabigatran [18].…”

Clinical Effectiveness and Safety Comparison between Reduced Rivaroxaban Dose and Dual Antiplatelet Therapy for Nonvalvular Atrial Fibrillation Patients Following Percutaneous Left Atrial Appendage Closure: A Prospective Observational Study

“…Activation of the coagulation system and enhanced thrombin generation without platelet aggregation were associated with DRT formation within days after LAAC [ 26 ]. In our results, persistent elevation of thrombosis size was also detected in the DAPT group after the procedure, which was consistent with the result of previous prospective studies.…”

Comparison of outcomes between novel oral anticoagulants and warfarin monotherapy in patients with left atrial appendage closure: A systematic review and meta-analysis

“…It seems to be superior to dabigatran to prevent DRT after LAAC ( 32 ). Rivaroxaban effectively reduced the occurrence of DRT after the LAAC procedure better than dabigatran, possibly because dabigatran increased platelet aggregation, thus increasing the risk of DRT ( 33 ). Low-dose dabigatran (110 mg twice a day) was associated with a higher risk of DRT at 45 days compared to warfarin ( 22 ).…”