Antithrombotic therapy in patients with non-valvular atrial fibrillation and high risk of stroke after successful endovascular left atrial appendage occlusion

Abstract

Aim. To assess the antithrombotic therapy after left atrial appendage occlusion (LAAO) with the Watchman device (WD) and Amplarzer Cardiac Plug (ACP) for stroke prevention in patients with nonvalvular atrial fibrillation (AF) with contraindications for long anticoagulation therapy.Methods. 200 consecutive patients with nonvalvular AF and contraindications to oral anticoagulation therapy with contraindications for long anticoagulation who undergone LAAO implantation using WD (n=108; WD group) and ACP (n=92; ACP group) were enrolled into this study. Antithrombotic therapies were prescribed after successful LAAO implantation according to indications. Patients were followed at 45 days, 3, 6 and 12 months after enrollment. At each follow-up visit the data regarding clinical events and healthcare utilization were collected. Transesophageal echo (TEE) was perfomed at 45 days and 6 months after successful LAAO implantation. The efficacy end point was the composite of transit ischemic attack (TIA)/stroke, device thrombosis and procedure-related death.Results. During the follow-up TIA/stroke has occurred in 4.8% of patients in the WD group with no such events in ACP group (4.8% vs 0%, p=0.062). These patients had 4 or more points on the CHA2 DS2 -VASc, and they were prescribed various combinations of antithrombotic therapy, except warfarin, while patients from the WD group with 4 or more points on the CHA2 DS2 -VASc score taking warfarin had no thromboembolic events. Device thrombosis during TEE at 45 days after successful LAAO implantation was confirmed in 3 patients (2,9%) with WD with no such events in ACP group (2.9% vs 0%, p=0.251). The efficacy end point events in all groups were 4.6%: 8 events in WD group (7.6%) and 1 case in ACP group (1.1%). One patient in the ACP group died in 6 weeks after LAAO implantation. No autopsy was performed; therefore, the exact cause of death was not determined (p=0.038). Survival rate showed significantly higher rate events in WD group versus ACP group (p=0.027).Conclusion. Any combinations of antithrombotic therapy could be prescribed to patients with contraindications for anticoagulant therapy and high risk of stroke who undergone successful (LAAO) implantation with Amplatzer Cardiac Plug. It’s possible to cancel oral anticoagulants in this patient. Patients aged 70 and older with a CHA2 DS2 -VASc >4 and a history of stroke are recommended to take warfarin after successful Watchman Device implantation.