Left Atrial Appendage Occlusion for Secondary Stroke Prevention in Patients with Atrial Fibrillation: Long-Term Results

Abstract

Background: Patients surviving an initial stroke present a significantly increased risk for further strokes. Left atrial appendage closure (LAAC) became an alternative treatment to pharmacological therapy for stroke prevention in atrial fibrillation (AF) patients. Objective: To evaluate the long-term efficacy of LAAC in primary and secondary stroke prevention in patients with AF. Methods: This retrospective study enrolled 139 patients following LAAC who were divided into 2 groups: 37 patients with prior stroke (Stroke Group) and 102 patients without stroke (Control Group). Overall, cumulative follow-up was 530.1 patient-years. Results: Mean CHADS2, CHA2DS2-VASc scores, and HAS-BLED score were higher in patients with prior stroke compared to patients without stroke (3.0 vs. 1.4, p < 0.0001 and 4.6 vs. 2.3, p < 0.0001, 4.0 vs. 2.8, p < 0.0001, respectively). There were no significant differences between other patient factors (sex, heart failure, hypertension, previous stroke/transient ischemic attack, peripheral vascular disease), which may increase the risk of thromboembolism based on the CHA2DS2-VASc score. Average follow-up was 51.3 months in patients with previous stroke and 50 months in patients without previous stroke. Thromboembolic event rate was 0.8 vs. 0.5 (p = 0.72), bleeding event rate was 0 years vs. 1.4 (p = 0.25), and mortality rates were 0.8 vs. 2.1 (p = 0.38) between the Stroke Group and the Control Group. The estimated reductions in thromboembolic and bleeding risks were 89 and 100%, respectively, in Stroke Group, and 91 and 81%, respectively, in Control Group. Conclusion: Patients with prior stroke may be the preferred group for LAAC regardless of the presence or absence of contraindications for anticoagulant therapy.

Response to Letter to the Editor “Adverse outcomes in anticoagulated patients undergoing percutaneous left atrial appendage ligation” by Anetta Undas

“…Although older age is listed as a risk factor for both bleeding and thromboembolism, we did not find a relationship with the incidence of adverse events, which is in line with our previous study [4]. It would be of interest to conduct a randomized trial comparing LAAO with no subsequent anticoagulation versus different anticoagulation strategies.…”

Causes of death and morbidity in patients with atrial fibrillation after left atrial appendage occlusion

“…First of all, our patients had multiple comorbidities as evidenced by a higher CHA 2 DS 2 -VAS score (mean, 5.0) and higher HAS -BLED score (mean, 4.4) compared with other LAAO clinical trials. 7,8, [20][21][22][23] In our study, most of the patients were older, with a mean age of 72 years, 69% had a history of severe bleeding, of whom 7.8% had central nervous system bleeding, 39% had a history of previous ischemic stroke, 40% had heart failure, 64% had evidence of vascular disease, 41% had diabetes mellitus, 100% had hypertension, and 2.4% were addicted to alcohol. Additionally, in our study, more than half of deaths (57%) were due to noncardiovascular causes with malignancy being the leading cause of death.…”

Comparative Safety and Efficacy of Left Atrial Appendage Occlusion with the Watchman Device and Amplatzer Cardiac Plug: Results of the Russian National Registry

“…Although the number of patients with prior stroke history was significantly higher in the ACP group, there were no clinically significant TIA/stroke episodes in this group. The possible explanation of such findings is the results of a study, conducted by Litwinowicz et al [ 17 ]. The authors evaluated the long-term efficacy of LAAO procedure in primary and secondary stroke prevention and reported comparable efficacy outcome during a mean follow-up of 50 months.…”