Left atrial appendage closure: a new strategy for cardioembolic events despite oral anticoagulation

Falasconi, Giulio; Gaspardone, Carlo; Godino, Cosmo; Gaspardone, Achille; Radinovic, Andrea; Pannone, Luigi; Leo, Giulio De; Posteraro, G; Slavich, Massimo; Melillo, Francesco; Marzi, Alessandra; D’Angelo, Giuseppe; Limite, Luca Rosario; Frontera, Antonio; Brugliera, Luigia; Agricola, Eustachio; Margonato, Alberto; Bella, Paolo Della; Mazzone, Patrizio

doi:10.23736/s0031-0808.21.04446-3

Cited by 8 publications

(9 citation statements)

References 19 publications

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“…A total of 10 studies [3 RCTs ( 6 , 8 , 15 ) and 7 PSM studies 16 – 22 ] involving 25,700 patients were identified. 12,961 patients received LAAC while 12,739 received OAC therapy.…”

Section: Resultsmentioning

confidence: 99%

Efficacy and safety of left atrial appendage closure compared with oral anticoagulation in atrial fibrillation: a meta-analysis of randomized controlled trials and propensity-matched studies

Franchin,

Piroli,

Demola

et al. 2023

Front. Cardiovasc. Med.

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BackgroundsTwo recent randomized controlled trials (RCTs), the PROTECT-AF and the PREVAIL, showed that in atrial fibrillation (AF) patients, left atrial appendage closure (LAAC) is comparable to oral anticoagulants (OAC) in the prevention of stroke and could also possibly reduce mortality. Nevertheless, this net clinical benefit was not confirmed in the most recent RCT comparing LAAC vs. OAC, the PRAGUE-17 trial.Aimaim of the present study was to evaluate the efficacy and safety of LAAC compared with OAC among available high-quality studies.MethodsA systematic search of electronic databases (Medline, Scopus, Embase and the Cochrane Library) was performed to identify eligible RCTs and observational studies with propensity score matching (PSM) analysis. PRISMA guidelines were used for abstracting data and assessing data quality and validity. Outcomes of interest were the occurrence of cardiovascular death (CVD), all-cause death, all-type stroke, and major bleedings.ResultsA total of 3 RCTs and 7 PMS studies involving 25,700 patients were identified. 12,961 patients received LAAC while 12,739 received OAC therapy. After a median follow-up of 2.6 years (IQR 2–4.4), patients who received LAAC had lower risk of CVD (RR = 0.62; 95%CI, 0.51–0.74, I2 = 0%), all-cause death (RR = 0.67; 95% CI, 0.57–0.78, I2 68%) and major bleedings (RR = 0.68; 95%CI, 0.48–0.95 I2 = 87%) compared with patients on OAC. No difference was found between the two groups regarding strokes incidence (RR = 0.94; 95% CI, 0.77–1.15, I2 = 0%).ConclusionsAccording to this meta-analysis, LAAC has comparable efficacy in the prevention of stroke compared with OAC and a reduced risk of major bleedings, all-cause death and CVD that may be even larger with longer follow-up.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=269768, identifier CRD42021269768.

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“…A total of 10 studies [3 RCTs ( 6 , 8 , 15 ) and 7 PSM studies 16 – 22 ] involving 25,700 patients were identified. 12,961 patients received LAAC while 12,739 received OAC therapy.…”

Section: Resultsmentioning

confidence: 99%

Efficacy and safety of left atrial appendage closure compared with oral anticoagulation in atrial fibrillation: a meta-analysis of randomized controlled trials and propensity-matched studies

Franchin,

Piroli,

Demola

et al. 2023

Front. Cardiovasc. Med.

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“…The full text of 18 studies was obtained, and a detailed evaluation was done based on the aforementioned inclusion and exclusion criteria. Finally, eight studies [10][11][12][13][14][15][16][17] were included in this metaanalysis, enrolling 7,629 participants with AF (4,287 in the DOAC group and 3,342 in the LAAC group). Figure 1 shows the PRISMA flowchart, demonstrating the study selection process.…”

Section: Resultsmentioning

confidence: 99%

Comparison of the Efficacy and Safety of Left Atrial Appendage Closure and Direct Oral Anticoagulants for Atrial Fibrillation: A Meta-Analysis of Randomized Control Trials and Observational Studies

Wei,

Lim,

Khan

et al. 2023

Cureus

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The aim of this study was to compare the efficacy and safety of left atrial appendage closure (LAAC) and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). This meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. Two investigators performed an online database search on PubMed, Web of Science, and Scopus databases from inception to October 31, 2023, without any language or time restrictions. Outcomes assessed in this meta-analysis included all-cause mortality, cardiovascular mortality, stroke, and major bleeding events. Eight studies were included in this meta-analysis, enrolling 7,629 participants with AF (4,287 in the DOAC group and 3,342 in the LAAC group). The pooled analysis showed that the risk of all-cause mortality was significantly higher in patients in the DOAC group compared to LAAC (relative risk (RR): 1.87, 95% confidence interval (CI): 1.50 to 2.34). The risk of cardiovascular mortality was 1.60 times higher in patients receiving DOACs compared to those receiving LAAC (RR: 1.60, 95% CI: 1.12 to 2.28). The risk of stroke was not significantly different between the two groups (RR: 1.15, 95% CI: 0.95 to 1.41). In conclusion, LAAC for AF patients proves to be safe and effective for stroke prevention, exhibiting a superior profile in terms of all-cause mortality, cardiovascular events, and major bleeding compared to oral anticoagulation (OAC). These findings prompt consideration of LAAC as a preferred treatment for cardiovascular event prevention in high-bleeding-risk patients.

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“…A call for therapeutic alternatives in patients with "valvular AF" and OAC failure LAAC in patients with AF and failure of OAC therapy is a continually expanding indication due to proved safety and efficacy of the procedure and no need for antithrombotic therapy enhancement [18,19]. However, all LAAC devices that have acquired commercial approvement so far were tested only in the specific population affected by non valvular AF and anticoagulant contraindication.…”

Section: Discussionmentioning

confidence: 99%

Left Atrial Appendage Closure in Patients With Mechanical Mitral Valve Prosthesis: A Multicenter Italian Pilot Study

Preda,

Margonato,

Gaspardone

et al. 2023

Preprint

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BackgroundIn patients with atrial fibrillation (AF) on vitamin K antagonist (VKA) therapy and therapeutical INR range the incidence of cardiac thromboembolism is not negligible and the subgroup carrying a mechanical prosthetic mitral valve (PMV) has the highest risk. We aimed to assess the long-term effects of left atrial appendage closure (LAAC) in AF patients carriers of mechanical PMV who experienced a failure of VKA therapy.MethodsIn this retrospective, multicenter study, patients who underwent LAAC because of thrombotic events including TIA/stroke, systemic embolism and evidence of left atrial appendage thrombosis/sludge during VKA therapy were enrolled. Patients with mechanical PMV were included and compared with controls. The primary endpoint was the composite of all-cause death, major cardiovascular events and major bleedings at follow-up. Feasibility and safety of LAAC was also assessed.ResultsA total of 55 patients (42% females; mean age 70 ± 9 years) including 12 carriers of mechanical PMV were enrolled. The most frequent indication to LAAC (71%) was LAA thrombosis or sludge. Procedural success was achieved in 96% of overall cases and in 100% of patients with PMV. In 35 patients a cerebral protection device was used. During a median follow-up of 6.1 ± 4.3 years, 4 patients with PMV and 20 patients without PMV reported adverse events (HR 0.73 [95% CI 0.25 – 2.16, p=0.564]).ConclusionLAAC seems to be a valuable alternative in AF patients with failure of VKA therapy who are carriers of mechanical PMV. This off-label, real-world clinical practice indication deserve validation in further studies.

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Left atrial appendage closure: a new strategy for cardioembolic events despite oral anticoagulation

Cited by 8 publications

References 19 publications

Efficacy and safety of left atrial appendage closure compared with oral anticoagulation in atrial fibrillation: a meta-analysis of randomized controlled trials and propensity-matched studies

Efficacy and safety of left atrial appendage closure compared with oral anticoagulation in atrial fibrillation: a meta-analysis of randomized controlled trials and propensity-matched studies

Comparison of the Efficacy and Safety of Left Atrial Appendage Closure and Direct Oral Anticoagulants for Atrial Fibrillation: A Meta-Analysis of Randomized Control Trials and Observational Studies

Left Atrial Appendage Closure in Patients With Mechanical Mitral Valve Prosthesis: A Multicenter Italian Pilot Study

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