Does LAAO reduce the composite of stroke recurrence, major bleeding, or all-cause mortality in AF patients with haemorrhagic transformation compared to usual care?
In AF patients with haemorrhagic transformation, LAAO was associated with a 76% reduction in the composite of stroke recurrence, major bleeding, or mortality compared to conservative treatment.
Abstract Background Ischemic stroke carries a substantial recurrence risk, particularly among patients with atrial fibrillation (AF). Left atrial appendage occlusion (LAAO) is an established stroke-prevention strategy, especially for individuals at increased risk of bleeding. Haemorrhagic transformation (HT), an acute complication of ischemic stroke, is not a standard indication for LAAO, and its role in this setting remains uncertain. We aimed to evaluate the outcomes of AF patients with HT who were treated with LAAO. Methods This retrospective cohort study was conducted at a large tertiary medical center between January 2018 and December 2024. Patients with AF and HT, without other indications for anticoagulation, were included. Those who underwent LAAO were compared to patients receiving usual care. The primary endpoint was a composite of stroke recurrence, major bleeding, or all-cause mortality. Treatment (LAAO vs. usual care) was modeled as a time-varying covariate to account for immortal time bias related to the interval before LAAO implantation. Results A total of 81 patients met the inclusion criteria: 20 treated with LAAO 40% female, mean age 76 (71–79) and 61 controls 51% female, mean age 79 (72–85). Freedom from the primary outcome was higher in the LAAO group compared with controls (75% vs. 35% at 22 months; log-rank p = 0.0026). In multivariable analysis, LAAO (hazard ratio HR = 0.233; 95% confidence interval CI, 0.087–0.626; p = 0.004) and female sex (HR = 0.441; 95% CI, 0.220–0.885; p = 0.021) were independently associated with risk reduction, while older age was associated with increased risk (HR = 1.067; 95% CI, 1.019–1.117; p = 0.006). A post-hoc analysis identified a non-linear association between age and risk, with patients aged 80 years showing a twofold increase in risk (HR = 2.010; 95% CI, 1.024–3.944; p = 0.0424). Conclusions In AF patients who developed haemorrhagic transformation, LAAO was associated with a 76% reduction in adverse outcomes compared with conservative treatment. Patients older than 80 years demonstrated a twofold higher risk. These findings suggest that LAAO may represent a promising alternative to long-term oral anticoagulation following HT. Further prospective studies are warranted to confirm these results.Time to composite outcome
Paroz et al. (Mon,) studied this question.