Percutaneous left atrial appendage closure versus nonvitamin K oral anticoagulants in patients with non-valvular atrial fibrillation and high bleeding risk

Cosmo Godino, Francesco Melillo, Barbara Bellini, Mattia Mazzucca, Carlo Andrea Pivato, Francesca Rubino, Filippo Figini, Patrizio Mazzone, Paolo Della Bella, Alberto Margonato, Antonio Colombo, Matteo Montorfano

Research output: Contribution to journalArticlepeer-review

Abstract

Aims: A significant number of patients with non-valvular atrial fibrillation (NVAF) are ineligible for nonvitamin K oral anticoagulants (NOACs) due to previous major bleeding or because they are at high bleeding risk (HBR). In this setting the indication for percutaneous left atrial appendage closure (LAAO) is a valuable alternative. We aimed to evaluate the efficacy and safety of NOACs versus LAAO indication in NVAF patients at HBR (HAS-BLED ≥3). Methods and results: All consecutive patients who underwent successful LAAO (n=193) and those treated with NOACs (n=189) (dabigatran, apixaban or rivaroxaban) were included. A 1:1 propensity score matching (PSM) was used to match LAAO and NOACs patients. At baseline, patients in the LAAO group had higher HAS-BLED (4.2% vs 3.3%, p<0.001) and lower CHADS-VASc (4.3% vs 4.7%, p=0.005) scores. After 1:1 PSM, 192 patients were enrolled in the final analysis (LAAO n=96; NOACs n=96). At two-year follow-up, no significant differences in thromboembolic (7.3% vs 6.3%, p=0.966) and ISTH major bleeding event rates (6.7% vs 4.8% p=0.503) were found between the two unmatched groups. All-cause death was significantly higher in the LAAO group (18.7% vs 10.6%; p=0.049). After PSM, all-cause death, thromboembolic and ISTH major bleeding event rates were similar between the groups. Significant independent predictors of all-cause death were dialysis (HR 5.65, 95% CI: 2.16-14.85, p<0.001) and age (HR 1.08, 95% CI: 1.05-1.13, p<0.001). Conclusions: In NVAF patients at HBR, LAAO and NOACs performed similarly in terms of thromboembolic and major bleeding events up to two-year follow-up. Our findings warrant further investigation in randomised trials and therefore can be considered as hypothesis-generating.

Original languageEnglish
Pages (from-to)1548-1554
Number of pages7
JournalEuroIntervention
Volume15
Issue number17
DOIs
Publication statusPublished - Apr 2020

Keywords

  • Anticoagulant therapy
  • Atrial fibrillation
  • Bleeding risk
  • LAA closure

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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