Antithrombotic Therapy After Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation

Freeman, James V.; Higgins, Angela; Wang, Yongfei; Du, Chengan; Friedman, Daniel J.; Daimee, Usama A.; Minges, Karl E.; Pereira, Lucy; Goldsweig, Andrew M.; Price, Matthew J.; Reddy, Vivek Y.; Gibson, Douglas; Doshi, Shephal K.; Varosy, Paul D.; Curtis, Jeptha P.

doi:10.1016/j.jacc.2022.02.047

Cited by 67 publications

(70 citation statements)

References 31 publications

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“…There could be a learning curve of the procedure since a study with data from 2016 to 2018 only reported 1,9% PDLs >5 mm. 15 …”

Section: Peridevice Leaksmentioning

confidence: 99%

“…It was recently documented that adherence to the U.S. Food and Drug administration post procedure protocols from the pivotal trials of LAAO was rare. 15 This includes medications, follow-up visits and imaging, with the most common deviation being the discharge with unstudied antithrombotic regimens. 15 …”

Section: Antithrombotic Therapymentioning

confidence: 99%

“… 15 This includes medications, follow-up visits and imaging, with the most common deviation being the discharge with unstudied antithrombotic regimens. 15 …”

Section: Antithrombotic Therapymentioning

confidence: 99%

“…There could be a learning curve of the procedure since a study with data from 2016 to 2018 only reported 1,9% PDLs >5 mm. 15 In the US NCDR LAAO Registry, 3%-4% were on warfarin or DOAC and more than 10% on a P2Y12 inhibitor at 1-year of follow-up. 8 This illustrates that in patients undergoing LAAO in everyday clinical practice, several patients remain on anticoagulation, which was the treatment the procedure was aiming to eliminate.…”

Section: Peridevice Leaksmentioning

confidence: 99%

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Percutaneous left atrial appendage occlusion discrepancy between randomised trials and clinical practice

2022

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In patients with atrial fibrillation and previous episodes of bleeding on oral anticoagulant treatment, left atrial appendage occlusion (LAAO) has emerged as an alternative way to decrease the risk of stroke.The use of the procedure has been on the rise, and the news coverage has been dominated by an uncritical acceptance of the benefit of this procedure, which probably have contributed to the increasing number of procedures.This commentary is a presentation and critical appraisal of the available evidence on the efficacy and safety of left atrial appendage closure as stroke prophylaxis.We illustrate that LAAO is supported by limited randomised data risk of serious complications, which we do not believe supports the current widespread use.

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“…There could be a learning curve of the procedure since a study with data from 2016 to 2018 only reported 1,9% PDLs >5 mm. 15 …”

Section: Peridevice Leaksmentioning

confidence: 99%

Section: Antithrombotic Therapymentioning

confidence: 99%

“… 15 This includes medications, follow-up visits and imaging, with the most common deviation being the discharge with unstudied antithrombotic regimens. 15 …”

Section: Antithrombotic Therapymentioning

confidence: 99%

Section: Peridevice Leaksmentioning

confidence: 99%

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Percutaneous left atrial appendage occlusion discrepancy between randomised trials and clinical practice

2022

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“…Theoretically, NOAC has fewer drugdrug interactions than warfarin and does not require a frequent blood draw to monitor the international normalized ratio (INR) (13). However, there is no consensus on the selection of novel oral anticoagulants (NOAC) and warfarin monotherapy after LAAC, and the results of clinical studies comparing the efficacy and safety of NOAC to warfarin monotherapy after LAAC were still inconclusive (14)(15)(16)(17)(18)(19)(20)(21)(22)(23).…”

Section: Introductionmentioning

confidence: 99%

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

Sun

Chen²,

Gao³

et al. 2022

Front. Cardiovasc. Med.

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BackgroundPivotal trials of percutaneous left atrial appendage closure (LAAC) used dedicated post-procedure antithrombotic protocols. However, there is no consensus on the selection of new oral anticoagulants (NOAC) and warfarin monotherapy after LAAC. This study aims to compare NOAC with warfarin monotherapy for efficacy and safety in patients undergoing LAAC.MethodsA database search was conducted using PubMed, EMBASE, Cochrane Library, and Clinicaltrials.gov for trials that compared NOAC with warfarin monotherapy after LAAC. The effective outcomes included any major adverse events (all-cause death, stroke, major bleeding) and their individual components. Safety outcomes included all-cause death, major bleeding, total bleeding, DRT, and PDL >5 mm.ResultsWe included 10 non-randomized clinical trials with 10,337 patients, of whom 4,960 patients received NOAC, while 5,377 patients received warfarin. There were no statistically significant differences in any major adverse events (LogOR: −0.11, 95% CI: −0.27, 0.04, P = 0.16), stroke (LogOR: 0.00, 95% CI: −0.42, 0.42, P = 1.00), all-cause death (LogOR: −0.23, 95% CI: −0.48, 0.02, P = 0.07), major bleeding (LogOR: −0.22, 95% CI: −0.45, 0.01, P = 0.06). NOAC was associated with a significant reduction in total bleeding (LogOR: −1.01, 95% CI: −1.47, −0.55, P < 0.0001) compared to warfarin. No statistically significant differences were found in DRT (LogOR: −0.19, 95% CI: −0.15, 0.52, P = 0.27) and PDL >5 mm (LogOR: 0.19, 95% CI: −0.33, 0.72, P = 0.47). Meta-regression and subgroup analysis showed that total bleeding (LogOR: −1.56, 95% CI: −2.15, −0.97, P < 0.001) was significantly lower in the NOAC group in the subgroup of <75 y.ConclusionAfter LAAC, NOAC monotherapy was associated with a lower risk of bleeding compared to warfarin monotherapy for 45 days. There was no significant difference between NOAC and warfarin in terms of other results.Systematic review registrationwww.york.ac.uk/inst/crd, identifier: CRD42022361244.

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Rethinking Anticoagulation for Left Atrial Appendage Closure

Guduguntla,

Patton

2024

JAMA Cardiol

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Antithrombotic Therapy After Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation

Cited by 67 publications

References 31 publications

Percutaneous left atrial appendage occlusion discrepancy between randomised trials and clinical practice

Percutaneous left atrial appendage occlusion discrepancy between randomised trials and clinical practice

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

Rethinking Anticoagulation for Left Atrial Appendage Closure

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