Left atrial appendage closure in patients with chronic kidney disease: results from the German multicentre LAARGE registry

Abstract

Objectives Chronic kidney disease (CKD) is associated with an increased complication rate after cardiac interventions. Although CKD has a high prevalence among atrial fibrillation patients, the impact of CKD on periprocedural complications and the outcome after an interventional left atrial appendage closure (LAAC) is unclear. The present study, therefore, aimed to investigate whether CKD influences the procedure's effectiveness and safety. Methods LAARGE is a prospective, non-randomised registry. LAAC was conducted with different standard commercial devices, and the follow-up period was one year. CKD was defined by an eGFR < 60 mL/min/1.73 m 2 , and subgroups were further analysed (i.e. eGFR < 15, 15-29, and 30-59 mL/min/1.73 m 2 , respectively). Results Two hundred ninety-nine of 623 patients (48.0%) revealed a CKD. The prevalence of cardiovascular comorbidity, CHA 2 DS 2 -VASc score (4.9 vs. 4.2), and HAS-BLED score (4.3 vs. 3.5) was significantly higher in CKD patients (each p < 0.001). Implantation success was similarly high across all GFR groups (97.9%). Periprocedural MACCE (0.7 vs. 0.3%), and other major complications (4.7 vs. 3.7%) were comparably infrequent. Survival free of stroke was significantly lower among CKD patients within 1 year (82.0 vs. 93.0%; p < 0.001; consistent after adjustment for confounding factors), without significant accentuation in advanced CKD (i.e. eGFR < 30 mL/min/1.73 m 2 ; p > 0.05 vs. eGFR 30-59 mL/min/1.73 m 2 ). Non-fatal strokes were absolutely infrequent during follow-up (0 vs. 1.1%). Severe non-fatal bleedings were observed only among CKD patients (1.4 vs. 0%; p = 0.021). Conclusions Despite an increased cardiovascular risk profile of CKD patients, device implantation was safe, and LAAC was associated with effective stroke prevention across all CKD stages.

JCS/JHRS 2021 guideline focused update on non‐pharmacotherapy of cardiac arrhythmias

“…In contrast to OACs, the effectiveness and safety of LAAC in patients with chronic renal failure regardless of severity have been reported. 173,174 However, a significant association between acute kidney disease (an absolute or a relative increase in serum creatinine of >0.3 mg/dL or ≥50% of baseline value) and higher mortality was reported, thus requiring preventive strategies, especially in patients with chronic kidney disease. 175 In the ESC and AHA/ACC/HRS guidelines, 110,176 percutaneous LAAC is classified as a Class IIb indication for stroke prevention in patients at an increased risk of stroke and with contraindications to long-term OAC therapy.…”

Left Atrial Appendage Closure: An Alternative to Anticoagulation for Stroke Prevention in Patients with Kidney Disease

“…Another large study investigating outcomes in CKD patients was published as part of the multicenter Left-Atrium-Appendage occluder Register Germany (LAARGE) (24). It was a nonrandomized prospective trial of 623 patients undergoing LAAO, including 299 patients with CKD, which reported similar implantation success and periprocedural major adverse cardiac events.…”

Clinical Evidence for the Choice of the Direct Oral Anticoagulant in Patients with Atrial Fibrillation According to Creatinine Clearance

“…Left atrial appendage occlusion (LAAO) represents a nonpharmacological alternative for stroke prevention in AF patients with end-stage renal disease or on hemodialysis [44]. A recent subanalysis of the LAARGE registry revealed that LAAO was safe and associated with effective stroke prevention across all CKD stages, including stage 5 (GFR < 15 mL/min/1.73 m 2 ) [45]. The available studies aimed to compare LAAO with anticoagulant therapy showed a non-inferiority of LAAO compared to warfarin [46,47].…”