Left atrial appendage occlusion for prevention of stroke in nonvalvular atrial fibrillation: a meta-analysis

Bode, Weeranun; Patel, Nikhil A.; Gehi, Anil K.

doi:10.1007/s10840-015-9988-1

Cited by 7 publications

(5 citation statements)

References 42 publications

(51 reference statements)

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“…28,31 Our findings corroborate and add to several recent systematic reviews. [37][38][39][40] A recently published patient-level meta-analysis of the Watchman device 41 similarly found no significant difference in risk of stroke between percutaneous LAA exclusion using the Watchman device and LT warfarin AE indicates adverse event; AF, atrial fibrillation; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CHF, congestive heart failure; CI, confidence interval; CVA, cerebrovascular accident; DM, diabetes mellitus; GI, gastrointestinal; HTN, hypertension; Hx, history (of); IABP, intra-aortic balloon pump; LAA, left atrial appendage; MI, myocardial infarction; n, number (of); NR, not reported; NS, not significant; PSM, propensity score matching; RR, relative risk; TEE, transesophageal echocardiography; TIA, transient ischemic attack; and VATS, video-assisted thoracoscopy.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of Left Atrial Appendage Exclusion Procedures to Reduce the Risk of Stroke: A Systematic Review of the Evidence

Noelck

Papak

Freeman

et al. 2016

Circ: Cardiovascular Quality and Outcomes

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Background-Atrial fibrillation is an important cause of cardioembolic stroke. Oral anticoagulants (OAC) reduce stroke risk but increase the risk of serious bleeding. Left atrial appendage (LAA) procedures have been developed to isolate the LAA from circulating blood flow, as an alternative to OAC. We conducted a systematic review of the benefits and harms of surgical and percutaneous LAA exclusion procedures. Methods and Results-We searched multiple data sources, including Ovid MEDLINE, Cochrane, and Embase, through January 7, 2015. Of 2567 citations, 20 primary studies met prespecified inclusion criteria. We abstracted data on patient characteristics, stroke, mortality, and adverse effects. We assessed study quality and graded the strength of evidence using published criteria. Trials found low-strength evidence that percutaneous LAA exclusion confers similar risks of stroke and mortality as continued OAC, but this evidence was limited to the Watchman device in patients eligible for long-term OAC. Observational studies found moderate-strength evidence of serious harms with a variety of percutaneous LAA procedures. There is low-strength evidence that surgical LAA exclusion does not add significant harm during heart surgery for another indication, but evidence on stroke reduction is insufficient. Conclusions-There is limited evidence that the Watchman device may be noninferior to long-term OAC in selected patients.Data on effectiveness of LAA exclusion devices is lacking in patients ineligible for long-term OAC. Percutaneous LAA devices are associated with high rates of procedure-related harms. Although surgical LAA exclusion during heart surgery does not seem to add incremental harm, there is insufficient evidence of benefit. (Circ Cardiovasc Qual Outcomes. 2016;9:395-405.

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Section: Discussionmentioning

confidence: 99%

Effectiveness of Left Atrial Appendage Exclusion Procedures to Reduce the Risk of Stroke: A Systematic Review of the Evidence

Noelck

Papak

Freeman

et al. 2016

Circ: Cardiovascular Quality and Outcomes

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“…Another meta-analysis [ 69 ] including 16 studies, was performed comparing 1759 LAAO patients versus a fictitious control group from the ATRIA study, the Danish national patient registry, and the results of three studies comparing DOACs with warfarin. The risk of stroke was reduced in percutaneous LAAO group in comparison with the others considered groups: no therapy or aspirin groups (RR 0.34; CI: 0.25–0.46) and warfarin group (RR 0.65; CI: 0.46–0.91).…”

Section: Advanced Data Analysis Exploring the Available Data On Laaomentioning

confidence: 99%

Percutaneous Left Atrial Appendage Occlusion: An Emerging Option in Patients with Atrial Fibrillation at High Risk of Bleeding

et al. 2021

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Atrial fibrillation (AF) is a common cardiac arrhythmia with an estimated prevalence of 1% in the general population. It is associated with an increased risk of ischemic stroke, silent cerebral ischemia, and cognitive impairment. Due to the blood flow stasis and morphology, thrombus formation occurs mainly in the left atrial appendage (LAA), particularly in the setting of nonvalvular AF (NVAF). Previous studies have shown that >90% of emboli related to NVAF originate from the LAA, thus prevention of systemic cardioembolism is indicated. According to the current guidelines, anticoagulant therapy with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs), represents the standard of care in AF patients, in order to prevent ischemic stroke and peripheral embolization. Although these drugs are widely used and DOACs have shown, compared to VKAs, non-inferiority for stroke prevention with significantly fewer bleeding complications, some issues remain a matter of debate, including contraindications, side effects, and adherence. An increasing number of patients, indeed, because of high bleeding risk or after experiencing life-threatening bleedings, must take anticoagulants with extreme caution if not contraindicated. While surgical closure or exclusion of LAA has been historically used in patients with AF with contradictory results, in the recent years, a novel procedure has emerged to prevent the cardioembolic stroke in these patients: The percutaneous left atrial appendage occlusion (LAAO). Different devices have been developed in recent years, though not all of them are approved in Europe and some are still under clinical investigation. Currently available devices have shown a significant decrease in bleeding risk while maintaining efficacy in preventing thromboembolism. The procedure can be performed percutaneously through the femoral vein access, under general anesthesia. A transseptal puncture is required to access left atrium and is guided by transesophageal echocardiography (TEE). Evidence from the current literature indicates that percutaneous LAAO represents a safe alternative for those patients with contraindications for long-term oral anticoagulation. This review summarizes scientific evidences regarding LAAO for stroke prevention including clinical indications and an adequate patient selection.

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“…However, the meta-analyses usually also include data from open registries. The metaanalysis by Bode et al included 16 studies with 1759 patients who received LAA closure [9]. The authors created a fictitious control group from data of the ATRIA study, the Danish national patient registry and the results of three studies comparing NOACs with warfarin.…”

Section: Meta-analyses and Systematic Reviewsmentioning

confidence: 99%

Percutaneous left Atrial Appendage Occlusion for Stroke Prevention in Patients with Atrial Fibrillation

Diener

Landmesser

2020

Future Neurol.

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Patients with atrial fibrillation (AF) have a fivefold higher risk of stroke than persons in sinus rhythm. Effective stroke prevention is achieved with oral anticoagulants such as vitamin K antagonists or nonvitamin K oral anticoagulants. An alternative for stroke prevention in patients with AF is the closure of the left atrial appendage (LAA) with a percutaneously applied closure system. The two large randomized studies PROTECT-AF and PREVAIL failed to show superiority of LAA closure over anticoagulation in patients with AF. Meta-analyses of studies and registries, however, suggest that LAA closure has particular advantages with regard to the reduction of severe bleeding complications. Currently, several prospective randomized studies are being conducted in different patient populations to evaluate the benefit of LAA closure in comparison to standard of care. Currently, LAA closure is recommended in patients after intracranial hemorrhage, with advanced renal failure, after severe gastrointestinal bleeding, in patients with a high risk of recurrent ischemic stroke and elderly patients with high risk of bleeding and falling.

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Left atrial appendage occlusion for prevention of stroke in nonvalvular atrial fibrillation: a meta-analysis

Cited by 7 publications

References 42 publications

Effectiveness of Left Atrial Appendage Exclusion Procedures to Reduce the Risk of Stroke: A Systematic Review of the Evidence

Effectiveness of Left Atrial Appendage Exclusion Procedures to Reduce the Risk of Stroke: A Systematic Review of the Evidence

Percutaneous Left Atrial Appendage Occlusion: An Emerging Option in Patients with Atrial Fibrillation at High Risk of Bleeding

Percutaneous left Atrial Appendage Occlusion for Stroke Prevention in Patients with Atrial Fibrillation

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