Left Atrial Appendage Occlusion in Patients With Anticoagulation Failure vs Anticoagulation Contraindication
Por:
Aarnink, EW, Maarse, M, Fierro, N, Mazzone, P, Beneduce, A, Tondo, C, Gasperetti, A, Pracon, R, Demkow, M, Zielinski, K, de Backer, O, Korsholm, K, Nielsen-Kudsk, JE, Estévez-Loureiro, R, Caneiro-Queija, B, Benito-González, T, de Prado, AP, Nombela-Franco, L, Salinas, P, Holmes, D, Almakadma, AH, Berti, S, Romeo, MR, Millan, X, Arzamendi, D, Alla, VM, Agarwal, H, Eitel, I, Paitazoglou, C, Freixa, X, Cepas-Guillén, P, Chothia, R, Badejoko, SO, Spoon, DB, Maddux, JT, El-Chami, M, Ram, P, Branca, L, Adamo, M, Suradi, HS, Peper, J, van Dijk, VF, Rensing, BJWM, Swaans, MJ, Vireca, E, Bergmann, MW, Boersma, LVA
Publicada:
10 jun 2024
Ahead of Print:
1 jun 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 bene fit from LAAO. OBJECTIVES This study sought to investigate the ef ficacy 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 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 signi ficant 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 1 / 4 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 contraindicated population in EWOLUTION. The thromboembolic event rate was higher and the bleeding rate lower, reftecting the intrinsically different risk pro file of both populations. Until randomized trials are available, LAAO may considered in patients with an ischemic event on OAT. (J Am Coll Cardiol Intv 2024;17:1311 -1321) (c) 2024 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Filiaciones:
Aarnink, EW:
Sint Antonius Ziekenhuis, Dept Cardiol, Nieuwegein, Netherlands
Univ Amsterdam, Dept Cardiol, Med Ctr, Amsterdam, Netherlands
Maarse, M:
Sint Antonius Ziekenhuis, Dept Cardiol, Nieuwegein, Netherlands
Univ Amsterdam, Dept Cardiol, Med Ctr, Amsterdam, Netherlands
Fierro, N:
Azienda Socio Sanit Territoriale Grande Osped Metr, De Gasperis Cardio Ctr, Intervent Cardiol Unit, Milan, Italy
Mazzone, P:
Azienda Socio Sanit Territoriale Grande Osped Metr, Arrhythmia Unit, Milan, Italy
Azienda Socio Sanit Territoriale Grande Osped Metr, Electrophysiol Labs, Milan, Italy
Beneduce, A:
Ist Sci San Raffaele, IRCCS, Milan, Italy
Tondo, C:
Ctr Cardiol Monzino, Dept Clin Electrophysiol & Cardiac Pacing, Inst Ricovero & Cura Carattere Sci, Milan, Italy
Univ Milan, Dept Biomed Surg & Dent Sci, Milan, Italy
Gasperetti, A:
Ctr Cardiol Monzino, Dept Clin Electrophysiol & Cardiac Pacing, Inst Ricovero & Cura Carattere Sci, Milan, Italy
Johns Hopkins Univ, Dept Cardiol, Baltimore, MD USA
Pracon, R:
Natl Inst Cardiol, Dept Coronary & Struct Heart Dis, Warsaw, Poland
Demkow, M:
Natl Inst Cardiol, Dept Coronary & Struct Heart Dis, Warsaw, Poland
Zielinski, K:
Natl Inst Cardiol, Dept Coronary & Struct Heart Dis, Warsaw, Poland
de Backer, O:
Rigshosp, Heart Ctr, Copenhagen, Denmark
Korsholm, K:
Aarhus Univ Hosp, Dept Cardiol, Aarhus, Denmark
Nielsen-Kudsk, JE:
Aarhus Univ Hosp, Dept Cardiol, Aarhus, Denmark
Estévez-Loureiro, R:
Univ Hosp Alvaro Cunqueiro, Intervent Cardiol Unit, Vigo, Spain
Caneiro-Queija, B:
Univ Hosp Alvaro Cunqueiro, Intervent Cardiol Unit, Vigo, Spain
Benito-González, T:
Univ Hosp Leon, Dept Cardiol, Leon, Spain
de Prado, AP:
Univ Hosp Alvaro Cunqueiro, Intervent Cardiol Unit, Vigo, Spain
Nombela-Franco, L:
Hosp Clin San Carlos, Inst Invest Sanit Hosp Clin San Carlos, Cardiovasc Inst, Madrid, Spain
Salinas, P:
Hosp Clin San Carlos, Inst Invest Sanit Hosp Clin San Carlos, Cardiovasc Inst, Madrid, Spain
Holmes, D:
Mayo Clin, Dept Cardiol, Rochester, MN USA
Almakadma, AH:
Mayo Clin, Dept Cardiol, Rochester, MN USA
Berti, S:
Fdn Toscana G Monasterio, Massa, Italy
Romeo, MR:
Fdn Toscana G Monasterio, Massa, Italy
Millan, X:
St Pau Res Inst, Cardiol Dept, Barcelona, Spain
Arzamendi, D:
St Pau Res Inst, Cardiol Dept, Barcelona, Spain
Alla, VM:
Creighton Univ, Sch Med, Omaha, NE USA
Agarwal, H:
Creighton Univ, Sch Med, Omaha, NE USA
Eitel, I:
Univ Heart Ctr Lubeck, Med Clin 2, Lubeck, Germany
German Ctr Cardiovasc Res DZHK, Partner Site Hamburg Kiel Lubeck, Lubeck, Germany
Paitazoglou, C:
Univ Heart Ctr Lubeck, Med Clin 2, Lubeck, Germany
German Ctr Cardiovasc Res DZHK, Partner Site Hamburg Kiel Lubeck, Lubeck, Germany
Freixa, X:
Hosp Clin Barcelona, Inst Clin Cardiovasc, Dept Cardiol, Barcelona, Spain
Cepas-Guillén, P:
Hosp Clin Barcelona, Inst Clin Cardiovasc, Dept Cardiol, Barcelona, Spain
Chothia, R:
St Josephs Med Ctr, Stockton, CA USA
Badejoko, SO:
St Josephs Med Ctr, Stockton, CA USA
Spoon, DB:
Providence Heart Inst, Dept Cardiol, Missoula, MT USA
Maddux, JT:
Providence Heart Inst, Dept Cardiol, Missoula, MT USA
El-Chami, M:
Emory Univ Hosp, Dept Cardiol, Atlanta, GA USA
Ram, P:
Emory Univ Hosp, Dept Cardiol, Atlanta, GA USA
Branca, L:
Univ Brescia, Dept Med & Surg Specialties Radiol Sci & Publ Hlth, Cardiol & Cardiac Catheterizat Lab, Azienda Socio Sanit Territoriale Spedali Civili Br, Brescia, Italy
Adamo, M:
Univ Brescia, Dept Med & Surg Specialties Radiol Sci & Publ Hlth, Cardiol & Cardiac Catheterizat Lab, Azienda Socio Sanit Territoriale Spedali Civili Br, Brescia, Italy
Suradi, HS:
Rush Univ, Med Ctr, Div Cardiovasc Med, Chicago, IL USA
Peper, J:
Sint Antonius Ziekenhuis, Dept Cardiol, Nieuwegein, Netherlands
van Dijk, VF:
Sint Antonius Ziekenhuis, Dept Cardiol, Nieuwegein, Netherlands
Rensing, BJWM:
Sint Antonius Ziekenhuis, Dept Cardiol, Nieuwegein, Netherlands
Swaans, MJ:
Sint Antonius Ziekenhuis, Dept Cardiol, Nieuwegein, Netherlands
Vireca, E:
Boston Sci, Diegem, Belgium
Bergmann, MW:
Asklepios Klin Altona, Dept Cardiol, Hamburg, Germany
Boersma, LVA:
Sint Antonius Ziekenhuis, Dept Cardiol, Nieuwegein, Netherlands
Univ Amsterdam, Dept Cardiol, Med Ctr, Amsterdam, Netherlands
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