Early Discontinuation of Antithrombotic Treatment Following Left Atrial Appendage Closure

https://doi.org/10.1016/j.amjcard.2022.01.055Get rights and content

Although antithrombotic treatment is recommended after left atrial appendage closure (LAAC), some patients require discontinuation of antithrombotic treatment after LAAC without evidence on the safety of such a strategy. We sought to evaluate outcomes of patients who had early antithrombotic treatment discontinuation after LAAC. This is a multicenter study including 1,082 patients who underwent successful LAAC. Early discontinuation of antithrombotic treatment was defined as discontinuation of all antiplatelet/anticoagulant treatment within 6 months following the procedure. A propensity-matched analysis was used to compare outcomes of patients with and without early antithrombotic treatment discontinuation. A total of 148 patients (13.7%) had early antithrombotic treatment discontinuation. In the entire population, antithrombotic treatment discontinuation patients exhibited a lower CHA2DS2-VASc score (p <0.001) and a higher rate of previous gastrointestinal bleeding episodes (p = 0.01) compared with patients without discontinuation. After a median follow-up of 2.1 (1,1-3.1) years after antithrombotic treatment discontinuation, the rates of death, ischemic stroke, and major bleeding were 12.1, 0.6, and 3.3 per 100 patient-years. In 119 matched pairs with similar baseline characteristics, antithrombotic treatment discontinuation patients had a similar risk of death (hazard ratio [HR] 1.06, 95% confidence interval [CI] 0.65 to 1.71, p = 0.82), ischemic stroke (HR 0.39, 95% CI 0.04 to 3.79, p = 0.42) and major bleeding (HR 1.48, 95% CI 0.56 to 3.88, p = 0.43) compared with those without discontinuation. In conclusion, antithrombotic treatment was discontinued in 1 of 7 selected patients within 6 months after LAAC, and this was not associated with an increased risk of death or thromboembolic events after a median follow-up of 2 years. These data support the safety of shorter periods of antithrombotic therapy after LAAC in high bleeding risk patients based on clinician judgment. Further trials are warranted.

Section snippets

Methods

From January 2011 to August 2018, a total of 1,094 consecutive patients with nonvalvular AF underwent LAAC closure in 8 centers in Europe and Canada and were included in a registry. Of them, 12 patients were excluded because of procedural death or unsuccessful LAAC leading to 1,082 patients finally being included in the study. Indication, device selection, and post-procedural management were at the discretion of the local team responsible for the patient, according to local recommendations. The

Results

A total of 148 (13.7%) had early complete discontinuation of antithrombotic treatment, at a median time of 90 (Q1 to 3 47 to 100) days after LAAC. Baseline and procedural characteristics according to early antithrombotic treatment discontinuation after LAAC are listed in Table 1. Patients with early antithrombotic treatment discontinuation exhibited a lower CHA2DS2-VASc score, and a lower prevalence of coronary artery and peripheral disease. Early antithrombotic discontinuation patients had a

Discussion

The main results of our study, including a large series of real-world patients with AF who underwent LAAC, can be summarized as follows: (1) ∼15% of patients were not treated with any antiplatelet or anticoagulant agent within 6 months (median 3 months) after LAAC, (2) antithrombotic discontinuation did not translate into an increase in the risk of thromboembolic events after a median follow-up of 2 years, and the rate of ischemic stroke remained much lower than expected, (3) antithrombotic

Disclosures

Dr. Cruz-González is a proctor for Boston Scientific, Abbott, and Lifetech. Dr. Nombela-Franco is a proctor for Abbott. Dr. Rodés-Cabau has received institutional research grants from Boston Scientific. The remaining authors have no conflicts of interest to declare.

Acknowledgment

Dr. Mesnier is supported by a research grant from the Férération Française de Cardiologie (Paris, France). Dr. Rodés-Cabau holds the Research Chair “Fondation Famille Jacques Larivière” for the Development of Structural Heart Disease Interventions.

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