Left atrial appendage closure in patients with failure of anticoagulation therapy: A multicenter comparative study on the hybrid strategy using DOACs and VKAs

Alberto Preda; Giulio Falasconi; Francesco Melillo; Davide Margonato; Giuseppe Antonio Posteraro; Ciro Vella; Alessandra Marzi; Fabrizio Guarracini; Paolo Della Bella; Eustachio Agricola; Achille Gaspardone; Matteo Montorfano; Patrizio Mazzone

doi:10.1016/j.ijcard.2024.132875

Left atrial appendage closure in patients with failure of anticoagulation therapy: A multicenter comparative study on the hybrid strategy using DOACs and VKAs

Int J Cardiol. 2024 Dec 5:421:132875. doi: 10.1016/j.ijcard.2024.132875. Online ahead of print.

Affiliations

¹ De Gasperis Cardio Center, Electrophysiology Unit, Niguarda Hospital, 20162 Milan, Italy. Electronic address: alberto.preda@ospedaleniguarda.it.
² De Gasperis Cardio Center, Electrophysiology Unit, Niguarda Hospital, 20162 Milan, Italy.
³ Cardiovascular Imaging Unit, San Raffaele Scientific Institute, 20132 Milan, Italy.
⁴ Division of Cardiology, San Eugenio Hospital, 00146 Rome, Italy.
⁵ Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy.
⁶ Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, 20132 Milan, Italy.

PMID: 39645044
DOI: 10.1016/j.ijcard.2024.132875

Abstract

Background: Patients with non-valvular atrial fibrillation (nvAF) who experienced a cardioembolic (CE) event despite adequate oral anticoagulation (OAC) are at high risk of recurrence and the combination between percutaneous left atrial appendage closure (LAAC) and long-term OAC may be a valuable option. The aim of this study was to compare the safety and the efficacy of post-LAAC long-term assumption of direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs) in this population.

Methods: Consecutive nvAF patients who experienced OAC failure despite adequate OAC therapy and underwent LAAC were retrospectively enrolled from three Italian centers. Patients were divided according to the anticoagulation strategy following LAAC: DOAC group and VKA group. The primary endpoint was a composite of all-cause death, CE event, and major bleeding, while secondary endpoint was a composite of CE event and major bleeding.

Results: Overall, 132 patients (39 % females; mean age 69 ± 11 years), including 73 patients on DOAC and 59 patients on VKA, were enrolled. At a median follow up of 61 ± 23 months, the DOAC group reported lower rate of primary endpoint (HR 0.42, 95 %CI 0.18-0.99, p = 0.038) and lower rate of secondary endpoint (HR 0.28, 95 %CI 0.09-0.89, p = 0.02). No significant differences were detected regarding the type of DOAC assumed. Previous cerebrovascular events, CHA2DS2-VASc, CHADS2, HAS-BLED, and renal dysfunction were predictors of the primary endpoint.

Conclusion: Long-term DOAC assumption was associated with higher free from primary and secondary endpoint with respect to VKA in nvAF patients undergoing LAAC for OAC failure.

Keywords: Cardioembolic events; Direct oral anticoagulant; Left atrial appendage closure; Left atrial appendage thrombosis; Oral anticoagulant; Stroke; Vitamin K antagonist.