Left Atrial Appendage Closure With Different Antithrombotic Therapies in Patients at High Bleeding Risk: A Ten-Year Cohort Study.
TL;DR
For high bleeding risk patients after LAAC, NOACs may provide a more favorable balance between thrombotic and bleeding risks, with lower DRT and fewer ischemic strokes, without increasing mortality.
Abstract
Background
This study aimed to evaluate the safety and efficacy of different antithrombotic strategy following left atrial appendage closure (LAAC) in high bleeding risk patients with non-valvular atrial fibrillation.
Methods
This study included 893 patients with high bleeding risk who successfully underwent LAAC and categorized them into four groups based on post-procedural antithrombotic regimen: single or dual antiplatelet therapy (SAPT, n = 27; DAPT, n = 143), warfarin (n = 97) and non-vitamin K antagonist oral anticoagulant (NOAC, n = 626). Kaplan-Meier survival curves and multivariate Cox regression were used.
Results
During a mean follow-up period of 46.17 months, NOAC group exhibited superior outcomes: lower incidence of mortality (8.1% vs. 10.5% for DAPT, 18.6% for warfarin and 14.8% for SAPT, p = 0.011), device-related thrombosis (DRT, 2.4% vs. 7.0% and 4.1%, p = 0.045), major bleeding (0.48% vs. 2.1%, 2.0% and 3.7%, p = 0.027) and major adverse cardiovascular event (MACE, 5.9% vs. 13.3%, 11.3% and 7.4%, p = 0.012). Rivaroxaban demonstrated greater efficacy in reducing mortality (6.9% vs. 13.1%), DRT (1.6% vs. 5.7%) and MACE (5.0% vs. 9.8%), compared to dabigatran (all p < 0.05). The 15mg dose demonstrated potential trend in reducing cardiac mortality and DRT (all p > 0.05).
Conclusions
For high bleeding risk patients after LAAC, NOACs may provide a more favorable balance between thrombotic and bleeding risks, with lower DRT and fewer ischemic strokes, without increasing mortality. Compared to the other doses, the 15-mg rivaroxaban group demonstrated a potentially superior trend.