Postprocedural Management: Anticoagulation and Beyond

Current practice and future prospects in left atrial appendage occlusion

The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion.

Percutaneous left atrial appendage occlusion

PURPOSE OF REVIEW

To review recent evidence evaluating the long-term safety and efficacy outcomes of left atrial appendage occlusion (LAAO), current guideline recommendations for LAAO use, performance of LAAO in comparison with direct oral anticoagulants (DOAC) and recently approved LAAO device.

RECENT FINDINGS

The last 18 months have been marked with increasing evidence of the utility of LAAO in patients who are not candidates for long-term oral anticoagulation (OAC). Long-term data from two continued access registries to PROTECT-AF and PREVAIL support LAAO as a safe and effective long-term anticoagulation therapy. This new evidence led to class IIb recommendation for LAAO in nonvalvular atrial fibrillation (NVAF) patients not eligible for long-term OAC. PRAGUE-17 randomized controlled trial showed LAAO is noninferior to DOAC lending support to use of this modality in current era. PINNACLE FLX trial showed improved implant success and adequate closure rate which led to the device's Food and Drug Administration approval.

SUMMARY

In conclusion, percutaneous LAAO appears to be a promising option for NVAF patients who are not candidates for long-term OAC in the current era. Further evidence guiding optimal patient selection and periprocedural antithrombotic regimen will help identify the patients who would benefit the most from this procedure.

Propensity-matched comparison of antiplatelet versus anticoagulant after left atrial appendage closure with the Watchman

BACKGROUND

Optimal antithrombotic therapy following left atrial appendage closure (LAAC) with the Watchman occluder remains uncertain. This study retrospectively compared clinical outcomes of a 3-month dual antiplatelet therapy (DAPT group) and a protocol of anticoagulation plus aspirin for 45 days followed by DAPT for 6 months (ACT group) after LAAC with the Watchman device.

METHODS

Of two Watchman registries (Coburg and Lichtenfels hospitals, Germany), 220 and 304 consecutive patients with successful LAAC were included. Patients in Coburg hospital received DAPT while they received ACT in Lichtenfels. After a 1:1 propensity score matching, 174 (DAPT) versus 174 (ACT) patients were compared by use of the primary efficacy endpoint of thromboembolic events and cardiovascular/unexplained death, the primary safety endpoint of nonprocedural related major bleeding events at follow-up, and the combined hazard endpoint, a composite of all above-mentioned hazards.

RESULTS

The mean age 77.5 ± 7.2 (DAPT) versus 77.3 ± 7.1 (ACT) years, CHA₂ DS₂ -VASc score 4.6 ± 1.5 versus 4.7 ± 1.6, and HAS-BLED score 3.3 ± 0.8 versus 3.3 ± 0.8 were similar. After 12 months, the clinical efficacy (13/174, 7.4% [DAPT] vs 11/174, 6.3% [ACT]; hazard ratio [HR], 0.84; 95% confidence interval [CI], 0.38-1.86; P = .66) and safety (6/174, 3.4% vs 8/174, 4.5%; HR, 0.86; 95% CI, 0.29-2.56; P = .79) as well as the combined hazard endpoint (18/174, 10.3% vs 18/174, 10.3%; HR,1.01; 95% CI, 0.53-1.95; P = .97) were comparable.

CONCLUSIONS

This study suggests comparable efficacy and safety of 3-month DAPT versus 6 weeks ACT plus aspirin following LAAC with the Watchman.