Real world data on left atrial appendage closure after severe bleeding in anticoagulated patients with atrial fibrillation: frequency and associated factors.

Background There are no "real world" data on the actual impact of percutaneous left atrial appendage closure (LAAC) programs in the management of embolic event prevention after a severe bleeding (SB) in anticoagulated patients with atrial fibrillation (AF). Purpose Our main objective was to investigate the frequency of LAAC in anticoagulated AF patients surviving a SB event and to describe the differential features of these patients versus those medically managed in Andalusia (South of Spain). Methods All consecutive patients discharged alive from January 1st, 2021 to December 31st, 2022, after an intracranial or gastrointestinal severe haemorrhage, who were previously anticoagulated for AF, in all public Andalusian hospitals with LAAC program, and who could be eligible either for LAAC or direct anticoagulant treatment were included in a retrospective, multicentre study. The frequency of a percutaneous LAAC strategy in the follow-up was registered. A comparative analysis of baseline features between those patients treated with LAAC and those medically managed was performed. Results Among a reference population of 7119044 inhabitants in 15 hospitals, 1403 patients were included in the study. Median age was 81 years [p25-75, 76-87 years] with 51.6% male patients. A LAAC procedure was performed in 114 patients (8.13%) at a median time of 5 [2-10] months after discharge. After adjusting for confounding variables in a logistic regression model, LAAC closure was independently associated with intracranial hemorrhage (ICH), previous bleeding events, at least moderate valvular disease, leukemia and aspirin use at admission; and was more infrequently performed in patients aged >80 years, with dementia, uncontrolled blood pressure, vitamin K antagonist use at admission and interventional treatment of the bleeding event (Table). Variables with univariate association with LAAC (p<0.10) but excluded in backward stepwise regression after showing no significant independent association were hypercholesterolemia (rate of LAAC 9.5% vs 6.5% in non-hypercholesterolemia, p=0.04), diabetes mellitus (9.6% vs 7.2%, p=0.096), ischemic heart disease (11.9% vs 7.4%, p=0.02), heart failure or left ventricular dysfunction (9.9% vs 7.1%, p=0.06), connective tissue disease (0.0% vs 8.3%, p=0.09), chronic obstructive pulmonary disease (5.3% vs 8.7%, p=0.08), peptic ulcer disease (11.9% vs 7.7%, p=0.09), baseline heart rate (70[64-80] vs 75[66-87] bpm, p=0.003) and platelet count (201[158-244] vs 212[166-269]/nL, p=0.08). Conclusions In anticoagulated patients with AF who survived a SB event in all public hospitals with LAAC program in a large European region in 2021-2022, and who were also eligible for anticoagulation with DOAC, only 8.13% were managed with a LAAC strategy. Several baseline features were independently associated with higher or lower frequency of this approach.