Key result
Minimal antithrombotics post-LAAO linked to a ~15% absolute reduction in 90-day bleeding among high-risk patients.
Why the study?
Evidence is limited for the practice of using short-term antithrombotic drugs after left atrial appendage occlusion to prevent device-related thrombus, and optimal strategies in high bleeding-risk patients remain unclear.
Does minimal antithrombotic treatment reduce bleeding without increasing stroke or device-related thrombus compared to standard care in high bleeding-risk patients undergoing LAAO?
Observational (n=75)
Does minimal antithrombotic treatment reduce bleeding without increasing stroke or device-related thrombus compared to standard care in high bleeding-risk patients undergoing LAAO?
Minimal antithrombotic therapy (none or aspirin alone) after LAAO in high bleeding-risk patients may reduce bleeding and mortality without increasing short-term stroke or device-related thrombus risk compared to standard dual antiplatelet or anticoagulation therapy.
Minimal antithrombotic therapy after LAAO may reduce bleeding without excess thrombosis; hypothesis-generating and requires randomized trials before practice change.
BACKGROUND: Patients with atrial fibrillation (AF) and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. Short-term anti-thrombotic drugs are used postprocedure to offset the risk of device-related thrombus, evidence for this practice is limited. OBJECTIVES: To investigate optimal postimplant antithrombotic strategy in high bleeding-risk patients. METHODS: Patients with AF and high-risk for both stroke and bleeding undergoing LAAO were advised their perioperative drug therapy by a multidisciplinary physician panel. Those deemed to be at higher risk of bleeding from anti-thrombotic drugs were assigned to minimal treatment with no antithrombotics or Aspirin-alone. The remaining patients received standard care (STG) with a 12 week course of dual-antiplatelets or anticoagulation postimplant. We compared mortality, device-related thrombus, ischemic stroke, and bleeding events during the 90 days postimplant and long-term. Event-free survival was assessed using Kaplan-Meier survival analysis, with logrank testing for statistical significance. RESULTS: Seventy-five patients underwent LAAO of whom 63 patients (84%) had a prior serious bleeding event. The 42 patients on minimal treatment were older (74.3 ± 7.7 vs. 71.2 ± 7.2) with higher HASBLED score (3.6 ± 0.9 vs. 3.3 ± 1.2) than the 33 patients having standard care. There were no device-related thrombi or strokes in either group at 90 days postprocedure; STG had more bleeding events (5/33 vs. 0/42, p = 0.01) with associated deaths (3/33 vs. 0/42, p = 0.05). During long-term follow-up (median 2.2 years), all patients transitioned onto no antithrombotic drugs (43 patients [61%]) or a single-antiplatelet (29 patients [39%]). There was no evidence of early minimal treatment adversely affecting long-term outcomes. CONCLUSIONS: Short-term anti-thrombotic drugs may not be needed after LAAO implant in patients with high bleeding risk and could be harmful. Larger, prospective studies would be warranted to test these findings.
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Kailey et al. (2023) conducted an observational in Atrial fibrillation and high bleeding risk (n=75). Minimal antithrombotic treatment (no antithrombotics or aspirin alone) vs. Standard care (12-week course of dual-antiplatelets or anticoagulation) was evaluated on Bleeding events at 90 days postimplant (p=0.01). Minimal antithrombotic treatment after LAAO in high bleeding-risk patients resulted in fewer bleeding events (0% vs 15.2%, p=0.01) and associated deaths (0% vs 9.1%, p=0.05) at 90 days.
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