Key result
A survey of 196 European physicians found that switching to another DOAC is the preferred initial treatment for malignant LAA, with LAA closure reserved for patients with higher bleeding risk.
Why the study?
The optimal treatment strategy to reduce stroke or systemic embolism risk in atrial fibrillation patients with malignant left atrial appendage is unknown.
What are the contemporary diagnostic and therapeutic pathways practiced by European physicians for patients with malignant left atrial appendage?
Cross-Sectional (n=196)
Yes
What are the contemporary diagnostic and therapeutic pathways practiced by European physicians for patients with malignant left atrial appendage?
This survey reveals that European physicians predominantly manage malignant left atrial appendage by switching anticoagulants, reserving left atrial appendage closure for patients with high bleeding risk or recurrent stroke.
Malignant LAA pathways remain heterogeneous across Europe; leaves open optimal therapy and requires prospective trials.
AIMS: Patients with atrial fibrillation who despite taking oral anti-coagulant therapy (OAT) suffer a stroke or systemic embolism (SSE) without vascular cause or who develop left atrial appendage (LAA) thrombus (LAAT) should be considered as having malignant LAA. The optimal treatment strategy to reduce SSE risk in such patients is unknown. The aim of the study is to investigate the diagnostic and therapeutic pathways for malignant LAA practiced in European cardiac centres. METHODS AND RESULTS: An 18-item online questionnaire on malignant LAA was disseminated by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee. A total of 196 physicians participated in the survey. There seems to be high confidence in transoesophageal echocardiography (TEE) imaging, considering LAAT diagnosis. Switching to another direct oral anti-coagulant (DOAC) is the preferred initial step for the treatment of malignant LAA followed by a switch to vitamin K antagonist (VKA), low-molecular-weight heparin, or continued/optimized DOAC dosage, whereas LAA closure is the last option. Left atrial appendage closure is a viable option in patients with embolic stroke despite OAT and no evidence of thrombus at TEE (empty LAA) after comprehensive diagnostic measures to exclude other sources of embolism. CONCLUSION: This EHRA survey provides a snapshot of the contemporary management of patients diagnosed with malignant LAA. Currently, the majority of patients are treated on an outpatient basis with either shifting from VKA to DOAC or from one DOAC to another. Left atrial appendage closure in this population seems to be reserved for patients with higher bleeding risk or complications of malignant LAA, such as stroke.
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Anić et al. (2023) conducted a cross-sectional in Malignant left atrial appendage (n=196). Physician survey on malignant LAA management was evaluated on Diagnostic and therapeutic pathways for malignant LAA. A survey of 196 European physicians found that switching to another DOAC is the preferred initial treatment for malignant LAA, with LAA closure reserved for patients with higher bleeding risk.
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