Key result
Thoracoscopic LAA exclusion without antithrombotics linked to ~15% higher cause-specific survival vs continued anticoagulation.
Why the study?
The role of left appendage occlusion is questioned due to assumed mandatory post-procedure antiplatelet therapy, whereas epicardial closure does not mandate it, warranting investigation of its safety and efficacy.
Does thoracoscopic epicardial appendage exclusion without antithrombotic therapy improve survival and reduce adverse events compared to continued anticoagulation in AF patients with poor tolerance to anticoagulants?
Cohort (n=425)
Does thoracoscopic epicardial appendage exclusion without antithrombotic therapy improve survival and reduce adverse events compared to continued anticoagulation in AF patients with poor tolerance to anticoagulants?
Absolute Event Rate: 98% vs 83%
p-value: p=<0.001
Thoracoscopic epicardial left atrial appendage exclusion without routine antithrombotic therapy is safe, improves survival, and enhances quality of life in AF patients poorly tolerant to anticoagulation.
Background and aims In 2024 ESC/EACTS guidelines for Atrial Fibrillation left appendage occlusion has a class indication IIb for stroke prevention in patients with contraindication to anticoagulation. With DOACS having same bleeding risk of aspirine the role of appendage occlusion is defined “unclear” on the assumption that post procedure antiplatelet therapy is mandatory. Endovascular closure mandate antiplatelet therapy, epicardial closure do not. Investigating safety and efficacy of thoracoscopic epicardial appendage exclusion without antiplatelet therapy might shed light on this topic with clinical implications. Methods Between 2016-2025, 425 patients with AF and poor tolerance to anticoagulants (CHA2DS2VA4.1±1.5, HASBLED3.2±1.1) underwent multidisciplinary evaluation for thoracoscopic epicardial appendage exclusion. No antithrombotic therapy was prescribed for entire follow up unless required for persistent left atrial thrombosis, or acute cardioembolic event on anticoagulants. Follow up was at 3,6,12 months and yearly thereafter,EQ-5D-5L was used for quality of life pre procedure and at 12 months Results 385 patients underwent thoracoscopic appendage exclusion, 40 continued anticoagulation. In thoracoscopy group at follow up 92% of patients received no antithrombotic therapy, 5.9% were on anticoagulants. In the treated groups overall incidence of stroke, composite outcomes, bleeding events were 0.46(95%CI:0.12-1.14), 0.79(0.32-1.62), 0.47(0.12-1.15) respectively. Cause specific survival was 100% vs 89% at 1 year and 98% vs 83% at 4years (p<0.001). EQ5D5L scores increased from median 50(IQR 40-60) to 74(IQR 70-78)(p<0.001)at 12 months. Conclusions Thoracoscopic epicardial left appendage exclusion without antiplatelet therapy is safe and effective in patient wiht AF poor tolerant to anticoagulants. Conflict of interest nothing to disclose
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Branzoli et al. (2026) conducted a cohort in Atrial Fibrillation with poor tolerance to anticoagulation (n=425). Thoracoscopic epicardial appendage exclusion without antithrombotic therapy vs. Continued anticoagulation was evaluated on Cause specific survival at 4 years (p=<0.001). Thoracoscopic epicardial appendage exclusion without antithrombotic therapy improved 4-year cause-specific survival compared to continued anticoagulation (98% vs 83%, p<0.001).
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