Interventions for hypertension and stroke

Percutaneous left atrial appendage closure versus non-vitamin K oral anticoagulants in patients with non-valvular atrial fibrillation and high bleeding risk

EuroIntervention 2020;15:1548-1554. DOI: 10.4244/EIJ-D-19-00507

Cosmo Godino
Cosmo Godino1, MD; Francesco Melillo1, MD; Barbara Bellini2, MD; Mattia Mazzucca1, MD; Carlo Andrea Pivato1, MD; Francesca Rubino1, MD; Filippo Figini2, MD; Patrizio Mazzone3, MD; Paolo Della Bella3, MD; Alberto Margonato1, MD; Antonio Colombo2, MD; Matteo Montorfano2, MD
1. Cardiology Unit, San Raffaele Hospital, Milan, Italy; 2. Interventional Cardiovascular Unit, San Raffaele Hospital, Milan, Italy; 3. Arrhythmia and Electrophysiology Unit, San Raffaele Hospital, Milan, Italy

Aims: A significant number of patients with non-valvular atrial fibrillation (NVAF) are ineligible for non-vitamin K oral anticoagulants (NOACs) due to previous major bleeding or because they are at high bleeding risk (HBR). In this setting the indication for percutaneous left atrial appendage closure (LAAO) is a valuable alternative. We aimed to evaluate the efficacy and safety of NOACs versus LAAO indication in NVAF patients at HBR (HAS-BLED ≥3).

Methods and results: All consecutive patients who underwent successful LAAO (n=193) and those treated with NOACs (n=189) (dabigatran, apixaban or rivaroxaban) were included. A 1:1 propensity score matching (PSM) was used to match LAAO and NOACs patients. At baseline, patients in the LAAO group had higher HAS-BLED (4.2% vs 3.3%, p<0.001) and lower CHADS-VASc (4.3% vs 4.7%, p=0.005) scores. After 1:1 PSM, 192 patients were enrolled in the final analysis (LAAO n=96; NOACs n=96). At two-year follow-up, no significant differences in thromboembolic (7.3% vs 6.3%, p=0.966) and ISTH major bleeding event rates (6.7% vs 4.8% p=0.503) were found between the two unmatched groups. All-cause death was significantly higher in the LAAO group (18.7% vs 10.6%; p=0.049). After PSM, all-cause death, thromboembolic and ISTH major bleeding event rates were similar between the groups. Significant independent predictors of all-cause death were dialysis (HR 5.65, 95% CI: 2.16-14.85, p<0.001) and age (HR 1.08, 95% CI: 1.05-1.13, p<0.001).

Conclusions: In NVAF patients at HBR, LAAO and NOACs performed similarly in terms of thromboembolic and major bleeding events up to two-year follow-up. Our findings warrant further investigation in randomised trials and therefore can be considered as hypothesis-generating.

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Anticoagulant therapyatrial fibrillationBleeding Risklaa closure
Interventions for strokeLAA closure
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