Safety and efficacy of different anticoagulation regimens after left atrial appendage occlusion

Li, Wei; Gao, Runfeng; Zhao, Juan; Yin, Rong; Chen, Gecai; Zhu, Junguo; Jin, Kai; Zhu, Li; Ruan, Zhongbao

doi:10.21037/apm-21-3654

Cited by 6 publications

(2 citation statements)

References 21 publications

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“…In conclusion, it was also demonstrated that NOAC + SAPT therapy was safe and effective in short-term follow-up and was associated with lower early DRT formation. 42 …”

Section: The Rationale For Antithrombotic Therapymentioning

confidence: 99%

The WATCHMAN Device Review: A new era for stroke prophylaxis

Khan¹,

Naz²,

Khan³

et al. 2023

Journal of Community Hospital Internal Medicine Perspectives

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Atrial fibrillation (AF) is a major risk factor for ischemic stroke, accounting for more than 37 million cases worldwide. In AF, the left atrial appendage (LAA) is the most common site of thrombus formation, and its ligation/closure with the WATCHMAN device is a good alternative to long-term oral anticoagulation, especially in patients with contraindications to warfarin. However, the implantation procedure is associated with various risks and complications. A short-term anticoagulant and antithrombotic administration are essential after implantation. However, no consensus has been reached on the optimal regimen. The WATCHMAN device is non-inferior to warfarin and is a safe alternative for the prevention of stroke and systemic embolization related to non-valvular atrial fibrillation (NVAF). Important procedure-related complications include pericardial effusion (PE), device embolization, procedure-related ischemic stroke, and device-related thrombosis (DRT) formation. It is essential to optimize post-implantation therapy according to individual patient bleeding risk, DRT formation, and contraindication to direct oral anticoagulants (DOACs). Recent studies have also shown that DOACs are a convenient and non-inferior substitute for warfarin. Furthermore, patients with absolute contraindications to OACs/DOACs can only be managed with dual antiplatelet therapy (DAPT). Transesophageal echocardiography (TEE) should be used to assess residual peridevice flow and possible DRT formation at days 45 and 12 months. Low molecular weight heparin (LMWH) and OAC are excellent choices for DRT treatment if detected. This review summarizes the most important complications of the WATCHMAN device in the existing literature and discusses various anticoagulation strategies and challenges post-implementation.

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“…In conclusion, it was also demonstrated that NOAC + SAPT therapy was safe and effective in short-term follow-up and was associated with lower early DRT formation. 42 …”

Section: The Rationale For Antithrombotic Therapymentioning

confidence: 99%

The WATCHMAN Device Review: A new era for stroke prophylaxis

Khan¹,

Naz²,

Khan³

et al. 2023

Journal of Community Hospital Internal Medicine Perspectives

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“…Это может указывать на роль сохраняющегося тромбообразования в левых отделах сердца на фоне приема антикоагулянтов у части больных [4]. Основным источником эмбологенных тромбов при нФП (>90% случаев) является левое предсердии (ЛП) и/или его ушко (уЛП) [5]. В среднем, часто-та тромбоза ЛП/уЛП у больных с ФП составляет ~3%, несмотря на использование антикоагулянтов [6].…”

Section: Introductionunclassified

Predictors of thrombosis of left atrium and its appendage before catheter ablation or cardioversion in patients with non-valvular atrial fibrillation or atrial flutter

Заиграев¹,

Yavelov²,

Drapkina³

et al. 2023

Cardiovasc Ther Prev

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Aim. To determine the incidence of left atrial (LA) and/or LA appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation (AF) (NAF) or atrial flutter (AFL) on transesophageal echocardiography (TEE) before elective catheter ablation (CA) or cardioversion (CV) and characterize the predictors of LA/LAA thrombosis among the indicators available in the routine practice of cardiologists and general practitioners.Material and methods. In this retrospective, single-center, casecontrol study, the medical records of 1994 patients with NAF or AFL for the period 2014-2019, who underwent TEE before CA or elective CV, were analyzed. A thrombus in the LA/LAA was detected in 33 (1,6%) of them. For the comparison group, 167 patients were randomly selected without LA/LAA thrombosis. Demographic, anamnestic and clinical parameters, transthoracic echocardiography data, and laboratory results were analyzed as potential predictors of LA/LAA thrombosis.Results. Patients with LA/LAA thrombosis were older (mean age, 64,8±1,6 vs 59,4±10,8 (p=0,01), more often had persistent or longstanding persistent AF, hypertension, heart failure, enlarged LA, lower left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate, as well as more severe symptoms according to the modified European Heart Rhythm Association (EHRA) score and a higher CHA2DS2-VASc score (median, 4,0 vs 2,0; p=0,0001). Oral anticoagulants were taken by 88% of patients; there were no significant differences in the presence and composition of anticoagulant therapy between the groups. Functional class (FC) according to the modified EHRA score (odds ratio (OR), 5,4; 95% confidence interval (CI): 1,9814,96; p=0,001) and LVEF were independent predictors of LA/LAA thrombosis (OR, 0,87; 95% CI: 0,80-0,95; p=0,002). For EHRA class 3-4, the OR was 5,1; 95% CI: 2,3-11,4 (p<0,0001), for LVEF <48% — 7,4; 95% CI: 1,2-46,7 (p=0,03). For EHRA class 3-4, the sensitivity for LA/LAA thrombosis was 93,7%, specificity — 71,9%, positive predictive value — 50,0%, negative predictive value — 87,6%; for LVEF <48% — 66,7, 32,3, 31,9 and 91,6%, respectively.Conclusion. In the studied group of patients with NAF or AFL, without severe structural heart disease and severe concomitant diseases, most of whom received oral anticoagulants, LA/LAA thrombosis at TEE before elective CA or CV was detected in 1,6% of cases. Among the indicators available in routine medical practice, the severity of arrhythmia symptoms, assessed by the modified EHRA score, and lower LVEF were independent predictors of LA/LAA thrombosis.

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Antithrombotic Regimen After Percutaneous Left Atrial Appendage Closure　― A Real-World Study ―

Ryuzaki

Kondo

Nakano

et al. 2023

Circ J

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enrollment have been excluded from previous large clinical studies, 4,5 so in many cases, the complete U.S. Food and Drug Administration (FDA)-approved postprocedural treatment protocols studied in pivotal trials of WATCHMAN are rarely adhered to and are adjusted for individual patients. 6 Findings from a large cohort study and metaanalysis on the safety and efficacy of postprocedural antithrombotic therapy at discharge are available, but few reports of long-term outcomes have been published. 7,8 The safety and efficacy of various antithrombotic regimens have been reported in small trials in other Western countries but these may result in an overdose in smaller-stature Japanese patients especially. 9 LAAC may become more widely used in Japan, and there is, therefore, a need for appropriate antithrombotic therapy for the Japanese population. 10 The aim of the present study was to discuss the safety and efficacy of reduced-dose postoperative antithrombotic therapy, especially in patients with HBR. Cardioembolic stroke is the most common adverse event in patients with atrial fibrillation (AF). Oral anticoagulants (OAC) are the gold standard for preventing stroke and systemic embolism, but some patients have contraindications to OAC therapy due to a high bleeding risk (HBR). In September 2019, the WATCHMAN TM left atrial appendage closure (LAAC) device (Boston Scientific, St. Paul, MN, USA) was commercially introduced in Japan as an alternative to anticoagulation therapy. In Japan, LAAC is approved for patients with nonvalvular AF (NVAF), long-term OAC use, and HBR (HAS-BLED score ≥3, a history of Bleeding Academic Research Consortium [BARC] type 3 bleeding, requiring dual antiplatelet therapy [DAPT] for ≥1 year, multiple episodes of falls requiring interventions, or a history of cerebral amyloid angiopathy). 1-3 However, anticoagulation therapy is required after the procedure to prevent device-related thrombosis (DRT), and the use of antithrombotic drugs after WATCHMAN implantation in patients with HBR is controversial. Patients with previous stroke/transient ischemic attack within 90 days of

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Safety and efficacy of different anticoagulation regimens after left atrial appendage occlusion

Cited by 6 publications

References 21 publications

The WATCHMAN Device Review: A new era for stroke prophylaxis

The WATCHMAN Device Review: A new era for stroke prophylaxis

Predictors of thrombosis of left atrium and its appendage before catheter ablation or cardioversion in patients with non-valvular atrial fibrillation or atrial flutter

Antithrombotic Regimen After Percutaneous Left Atrial Appendage Closure　― A Real-World Study ―

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Safety and efficacy of different anticoagulation regimens after left atrial appendage occlusion

Cited by 6 publications

References 21 publications

The WATCHMAN Device Review: A new era for stroke prophylaxis

The WATCHMAN Device Review: A new era for stroke prophylaxis

Predictors of thrombosis of left atrium and its appendage before catheter ablation or cardioversion in patients with non-valvular atrial fibrillation or atrial flutter

Antithrombotic Regimen After Percutaneous Left Atrial Appendage Closure ― A Real-World Study ―

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Antithrombotic Regimen After Percutaneous Left Atrial Appendage Closure　― A Real-World Study ―