Left Atrial Appendage Occlusion in Patients With Anticoagulation Failure vs Anticoagulation Contraindication
Aarnink, E.W. (Amsterdam University Medical Center)
Beneduce, A. (IRCCS San Raffaele Scientific Institute (Milà, Itàlia))
Gasperetti, Alessio (Johns Hopkins University)
Pracon, R. (National Institute of Cardiology)
Estevez-Loureiro, Rodrigo (Hospital Álvaro Cunqueiro (Vigo))
Benito-González, Tomás (Hospital Universitario de León)
Nombela-Franco, Luís (Instituto de Investigación Sanitaria del Hospital Clínico San Carlos)
Arzamendi, Dabit (Institut de Recerca Sant Pau)
Freixa, Xavier (Hospital Clínic i Provincial de Barcelona)
Adamo, Marianna (University of Brescia)
Suradi, H.S. (Rush University Medical Center)
Peper, J. (Sint Antonius Ziekenhuis)
Maarse, Moniek (Amsterdam University Medical Center)
Fierro, Nicolai (Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda)
Mazzone, P. (Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda)
Tondo, Claudio (University of Milan)
Demkow, M. (National Institute of Cardiology)
Zieliński, K. (National Institute of Cardiology)
de Backer, O. (University of Copenhagen)
Korsholm, K. (Aarhus University Hospital (Aarhus, Dinamarca))
Nielsen-Kudsk, J.E. (Aarhus University Hospital (Aarhus, Dinamarca))
Caneiro-Queija, B. (Hospital Álvaro Cunqueiro (Vigo))
Pérez de Prado, Armando (Hospital Universitario de León)
Salinas, Pablo (Instituto de Investigación Sanitaria del Hospital Clínico San Carlos)
Holmes, D. (Mayo Clinic)
Almakadma, A.H. (Mayo Clinic)
Berti, Sergio (Fondazione Toscana Gabriele Monasterio)
Romeo, M.R. (Fondazione Toscana Gabriele Monasterio)
Millan, Xavier (Institut de Recerca Sant Pau)
Alla, V.M. (Creighton University School of Medicine)
Agarwal, H. (Creighton University School of Medicine)
Eitel, I. (German Center for Cardiovascular Research (DZHK))
Paitazoglou, C. (German Center for Cardiovascular Research (DZHK))
Cepas-Guillén, Pedro (Hospital Clínic i Provincial de Barcelona)
Chothia, R. (St. Joseph's Medical Center)
Badejoko, S.O. (St. Joseph's Medical Center)
Spoon, D.B. (Providence Heart Institute)
Maddux, J.T. (Providence Heart Institute)
El-Chami, M. (Emory University Hospital)
Ram, P. (Emory University Hospital)
Branca, L. (University of Brescia)
van Dijk, V.F. (Sint Antonius Ziekenhuis)
Rensing, B.J.W.M. (Sint Antonius Ziekenhuis)
Swaans, M.J. (Sint Antonius Ziekenhuis)
Vireca, E. (Boston Scientific)
Bergmann, M.W. (Department of Cardiology)
Boersma, L.V.A. (Amsterdam University Medical Center)
Universitat Autònoma de Barcelona. Departament de Medicina

Fecha:	2024
Resumen:	Background: Left atrial appendage occlusion (LAAO) provides mechanical cardioembolic protection for atrial fibrillation (AF) patients who cannot use oral anticoagulation therapy (OAT). Patients with a thrombotic event despite OAT are at high risk for recurrence and may also benefit from LAAO. Objectives: This study sought to investigate the efficacy of LAAO in AF patients with a thrombotic event on OAT compared to: 1) LAAO in AF patients with a contraindication for OAT; and 2) historical data. Methods: The international LAAO after stroke despite oral anticoagulation (STR-OAC LAAO) collaboration included patients who underwent LAAO because of thrombotic events on OAT. This cohort underwent propensity score matching and was compared to the EWOLUTION (Evaluating Real-Life Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology) registry, which represents patients who underwent LAAO because of OAT contraindications. The primary outcome was ischemic stroke. Event rates were compared between cohorts and with historical data without OAT, yielding relative risk reductions based on risk scores. Results: Analysis of 438 matched pairs revealed no significant difference in the ischemic stroke rate between the STR-OAC LAAO and EWOLUTION cohorts (2. 5% vs 1. 9%; HR: 1. 37; 95% CI: 0. 72-2. 61). STR-OAC LAAO patients exhibited a higher thromboembolic risk (HR: 1. 71; 95% CI: 1. 04-2. 83) but lower bleeding risk (HR: 0. 39; 95% CI: 0. 18-0. 88) compared to EWOLUTION patients. The mortality rate was slightly higher in EWOLUTION (4. 3% vs 6. 9%; log-rank P = 0. 028). Relative risk reductions for ischemic stroke were 70% and 78% in STR-OAC LAAO and EWOLUTION, respectively, compared to historical data without OAT. Conclusions: LAAO in patients with a thrombotic event on OAT demonstrated comparable stroke rates to the OAT contraindicated population in EWOLUTION. The thromboembolic event rate was higher and the bleeding rate lower, reflecting the intrinsically different risk profile of both populations. Until randomized trials are available, LAAO may be considered in patients with an ischemic event on OAT.
Derechos:	Aquest document està subjecte a una llicència d'ús Creative Commons. Es permet la reproducció total o parcial, la distribució, la comunicació pública de l'obra i la creació d'obres derivades, fins i tot amb finalitats comercials, sempre i quan es reconegui l'autoria de l'obra original.
Lengua:	Anglès
Documento:	Article ; recerca ; Versió publicada
Materia:	Anticoagulation failure ; Atrial fibrillation ; Ischemic stroke ; Left atrial appendage occlusion
Publicado en:	JACC: Cardiovascular Interventions, Vol. 17, Num. 11 (October 2024) , p. 1311-1321, ISSN 1876-7605

DOI: 10.1016/j.jcin.2024.04.012
PMID: 38795093

11 p, 1.3 MB

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