Left atrial appendage closure for atrial fibrillation patients at high risk of gastrointestinal bleeding. An evidence-based multidisciplinary review for gastroenterologists

BACKGROUND: atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, constituting a significant risk factor for stroke and systemic embolism. Oral anticoagulation (OAC) remains the primary strategy for stroke prevention, however, a subset of patients must discontinue it due to adverse events. Percutaneous left atrial appendage closure (LAAC) involves the mechanical occlusion of the left atrial appendage, an embryonic remnant in the left atrium of the heart where most thrombi form in patients with AF. It offers an alternative to long-term OAC for stroke prevention. METHODS: this article provides an overview of the LAAC procedure, its indications, and the current evidence (including clinical trials, meta-analyses, and real-world practice studies) regarding gastrointestinal bleeding (GIB) secondary to OAC. RESULTS: The PROTECT-AF and PREVAIL RCTs included 1114 patients with non-valvular AF, randomized 2:1 to LAAC or warfarin. Differences in major bleeding favoured LAAC (HR 0.48; 95% CI: 0.32-0.71). In the PRAGUE-17 trial, LAAC was non-inferior to DOAC in preventing major AF-related cardiovascular, neurological and bleeding events among patients at high risk for stroke and bleeding. In the long-term follow-up, the noninferiority of LAAC was maintained after 4 years (annual rate of nonprocedural clinically relevant bleeding, including GIB, was 7.42% for DOAC vs 3.76% for LAAC). In the OPTION trial, LAAC reduced non-procedure-related major or clinically relevant nonmajor bleeding at 36 months compared to OAC in patients undergoing catheter-based AF ablation. In a real-world study about LAAC in 43 anticoagulated patients with previous GIB, hospitalization need, number of endoscopic procedures, as well as iron intravenous doses and packed red cells administered decreased after LAAC. In cirrhosis, LAAC appears to be associated with an increased risk of complications (renal failure, cardiac tamponade, GIB) and readmissions. CONCLUSIONS: LAAC offers a treatment option for stroke prevention in AF patients in whom lifelong anticoagulation is contraindicated due to recurrent GIB, chronic anaemia or high bleeding risk. In cirrhotic patients, careful selection and shared decision-making are critical due to its higher complications risk.