Left Atrial Appendage Occlusion vs Standard of Care After Ischemic Stroke Despite Anticoagulation. (2024)

Afiliação

• Maarse M; Department of Cardiology, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands.
• Seiffge DJ; Department of Cardiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands.
• Werring DJ; Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland.
• Boersma LVA; UCL Queen Square Institute of Neurology, UCL London, United Kingdom.
• Mazzone P; Department of Cardiology, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands.
• Beneduce A; Department of Cardiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands.
• Tondo C; De Gasperis Cardio Center, Interventional Cardiology Unit, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy.
• Gasperetti A; Arrhythmia Unit and Electrophysiology Laboratories, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy.
• Pracon R; IRCCS, San Raffaele Scientific Institute, Milan, Italy.
• Demkow M; Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
• Zielinski K; Department of Biomedical, Surgical and Dental Sciences University of Milan, Milan, Italy.
• de Backer O; Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
• Korsholm K; Department of Cardiology, Johns Hopkins University, Baltimore, Maryland.
• Nielsen-Kudsk JE; Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland.
• Estévez-Loureiro R; Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland.
• Caneiro-Queija B; Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland.
• Benito-González T; Heart Center, Rigshospitalet, Copenhagen, Denmark.
• de Prado AP; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
• Nombela-Franco L; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
• Salinas P; Interventional Cardiology Unit, University Hospital Álvaro Cunqueiro, Vigo, Spain.
• Holmes D; Interventional Cardiology Unit, University Hospital Álvaro Cunqueiro, Vigo, Spain.
• Almakadma AH; Department of Cardiology, University Hospital of León, León, Spain.
• Berti S; Department of Cardiology, University Hospital of León, León, Spain.
• Romeo MR; Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain.
• Alvarez XM; Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain.
• Arzamendi D; Department of Cardiology, Mayo Clinic, Rochester, Minnesota.
• Alla VM; Department of Cardiology, Mayo Clinic, Rochester, Minnesota.
• Agarwal H; Fondazione Toscana "G. Monasterio," Massa, Italy.
• Eitel I; Fondazione Toscana "G. Monasterio," Massa, Italy.
• Paitazoglou C; Cardiology Department, Sant Pau Research institute (IIB Sant Pau), Barcelona, Spain.
• Freixa X; Cardiology Department, Sant Pau Research institute (IIB Sant Pau), Barcelona, Spain.
• Cepas-Guillén P; Creighton University School of Medicine, Omaha, Nebraska.
• Chothia R; Creighton University School of Medicine, Omaha, Nebraska.
• Badejoko SO; Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.
• Bergmann MW; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg - Kiel - Lübeck, Lübeck, Germany.
• Spoon DB; Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.
• Maddux JT; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg - Kiel - Lübeck, Lübeck, Germany.
• El-Chami M; Department of Cardiology, Institut Clinic Cardiovascular, Hospital Clínic of Barcelona, Barcelona, Spain.
• Ram P; Department of Cardiology, Institut Clinic Cardiovascular, Hospital Clínic of Barcelona, Barcelona, Spain.
• Branca L; St Joseph's Medical Center, Stockton, California.
• Adamo M; St Joseph's Medical Center, Stockton, California.
• Suradi HS; Department of Cardiology, AK Altona, Hamburg, Germany.
• van Dijk VF; Department of Cardiology, Providence Heart Institute, Missoula, Montana.
• Rensing BJWM; Department of Cardiology, Providence Heart Institute, Missoula, Montana.
• Zietz A; Department of Cardiology, Emory University Hospital, Atlanta, Georgia.
• Paciaroni M; Department of Cardiology, Emory University Hospital, Atlanta, Georgia.
• Caso V; Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
• Koga M; Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.

ABSTRACT

Importance Patients with atrial fibrillation (AF) who have ischemic stroke despite taking oral anticoagulation therapy (OAT) have a very high risk of recurrence. Left atrial appendage occlusion (LAAO) is a mechanical stroke prevention strategy that may provide additional protection in patients with thromboembolic events under OAT.

Objective:

To compare percutaneous LAAO with continuing OAT alone regarding stroke prevention in patients with AF who had a thromboembolic event despite taking OAT. Design, Setting, and

Participants:

This cohort study was a propensity score-matched comparison of the STR-OAC LAAO cohort, an international collaboration of 21 sites combining patients from multiple prospective registries of patients who underwent LAAO between 2010 and 2022. STR-OAC LAAO cohort patients who had follow-up longer than 3 months were propensity score-matched to a previously published control cohort comprising patients from an established international collaboration of investigator-initiated prospective studies. This control cohort included patients with nonvalvular AF, recent ischemic stroke or transient ischemic attack, and follow-up longer than 3 months who were taking OAT before the index event. Analyses were adjusted for imbalances in gender, age, hypertension, diabetes, and CHA2 DS2-VASc score. Exposure Left atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group). Main Outcomes and

Measures:

The primary outcome was time to first ischemic stroke.

Results:

Four hundred thirty-three patients from the STR-OAC LAAO cohort (mean [SD] age, 72 [9] years; 171 [39%] females and 262 [61%] males; mean [SD] CHA2 DS2-VASc score, 5.0 [1.6]) were matched to 433 of 1140 patients (38%) from the control group. During 2-year follow-up, 50 patients experienced ischemic stroke an annualized event rate of 2.8% per patient-year in the STR-OAC LAAO group vs 8.9% per patient-year in the control group. Left atrial appendage occlusion was associated with a lower risk of ischemic stroke (hazard ratio, 0.33; 95% CI, 0.19-0.58; P < .001) compared with the control group. After LAAO, OAT was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued OAT after LAAO as an adjunctive therapy. Conclusions and Relevance In patients with nonvalvular AF and a prior thromboembolic event despite taking OAT, LAAO was associated with a lower risk of ischemic stroke compared with continued OAT alone. Randomized clinical trial data are needed to confirm that LAAO may be a promising treatment option for this population with a very high risk of stroke.

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11420820
• https://dx.doi.org/10.1001/jamaneurol.2024.2882