Left atrial appendage occlusion for atrial fibrillation and bleeding diathesis

• Published in: European journal of arrhythmia & electrophysiology 2022-01, Vol.8, p.113
• Main Authors: Kailey, B S, Koa-Wing, M, Sutaria, N, Mott, T, Sohaib, A, Qureshi, N, Wadsworth, C, Jamil, S, L D’Anna, Shi, C, Padam, P, Howard, J, Levy, S, Porter, B, Whinnett, Z, Linton, N, Lim, B, Peters, N, Ng, F S, Keene, D, Malcolme-Lawes, L, Lefroy, D, Cole, G, Asaria, P, Ariff, B, Gopalan, D, Varnava, A, Pabari, P, Rana, B, Kanagaratnam, P
• Format: Article
• Language: English
• Subjects: Blood clots; Cardiac arrhythmia; Drugs; Stroke; Survival analysis
• ISSN: 2058-3869; 2058-3877

Introduction: Patients with atrial fibrillation (AF) and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. A short course of anti-thrombotic drugs is used post-procedure to offset the risk of device-related thrombus, but evidence for this practice is limited. Methods: Patients with AF and high risk for both stroke and bleeding were advised about their management strategy by a multidisciplinary physician panel. This included the perioperative drug therapy for those patients advised to undergo LAAO. Those deemed to be at unduly high risk of bleeding from anti-thrombotic drugs were assigned to minimal treatment with no anti-thrombotic drugs or aspirin alone. The remaining patients received standard care with a 6–12-week course of dual antiplatelets or anticoagulation following device implant. We compared mortality, device-related thrombus, ischaemic stroke and bleeding events during the 90 days post-implant and long term. Event-free survival was assessed using Kaplan–Meier survival analysis, with log rank testing for statistical significance. Results: A total of 75 patients underwent LAAO (Amulet™, Abbott Medical) of whom 63 (84%) had a prior serious bleeding event. The 42 patients on minimal treatment were older (74.3 ± 7.7 vs 71.2 ± 7.2) and had higher HASBLED score (3.6 ± 0.9 vs 3.3 ± 1.2) than the 33 patients receiving standard care. There were no device-related thrombi or strokes in either group in the 90 days post-procedure, but patients having standard treatment had more bleeding events (5/33 vs 0/42; p=0.01) with associated deaths (3/33 vs 0/42; p=0.05). During median long-term follow-up of 2.2 years, all patients were transitioned onto no antithrombotic drugs (43 patients [61%]) or a single antiplatelet (29 patients [39%]). There was no evidence of early minimal treatment adversely affecting long-term outcomes. Conclusions: Short-term anti-thrombotic drugs are not needed after LAAO implant in patients with high bleeding risk and this is the first clinical study to show that they may be harmful. ❑ [Image Omitted]