Left atrial appendage closure in end‐stage renal disease and hemodialysis: Data from a German multicenter registry

Thomas Fink; Christina Paitazoglou; Martin Bergmann; Makoto Sano; Vanessa Sciacca; Mohammed Saad; Charlotte Eitel; Christian‐Hendrik Heeger; Carsten Skurk; Ulf Landmesser; Hölger Thiele; Thomas Stiermaier; Georg Fuernau; Jan‐Christian Reil; Norbert Frey; Karl‐Heinz Kück; Roland Richard Tilz; Marcus Sandri; Ingo Eitel

doi:10.1002/ccd.30559

Why the study?

Optimal antithrombotic management of AF patients with ESRD is unknown, and LAAC has not been proven in these patients in prospective randomized clinical trials.

Does left atrial appendage closure have comparable safety and efficacy in atrial fibrillation patients with end-stage renal disease compared to those without severe chronic kidney disease?

Structured PICO

Does left atrial appendage closure have comparable safety and efficacy in atrial fibrillation patients with end-stage renal disease compared to those without severe chronic kidney disease?

P

Population

604 patients with atrial fibrillation undergoing left atrial appendage closure, including 57 with end-stage renal disease (eGFR < 15 ml/min/1.73 m2 or chronic hemodialysis) and 57 propensity-matched patients without severe chronic kidney disease.

I

Intervention

Left atrial appendage closure (LAAC)

C

Comparator

Propensity score-matched patients without severe chronic kidney disease undergoing LAAC

O

Outcome

Composite of ischemic stroke/transient ischemic attack, systemic embolism, and/or major clinical bleedingcomposite

Left atrial appendage closure appears to have comparable procedural safety and clinical efficacy in atrial fibrillation patients with end-stage renal disease compared to those without severe chronic kidney disease.

Implication

Supports LAA closure feasibility in ESRD; leaves open randomized confirmation of efficacy.

Abstract

Background Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). OAC treatment has been proven feasible in mild‐to‐moderate chronic kidney disease (CKD). In contrast, the optimal antithrombotic management of AF patients with end‐stage renal disease (ESRD) is unknown and LAAC has not been proven in these patients in prospective randomized clinical trials. Objectives The objective of this study is to evaluate safety and efficacy of LAAC in patients with ESRD. Methods Patients undergoing LAAC were collected in a German multicenter real‐world observational registry. A composite endpoint consisting of the occurrence of ischemic stroke/transient ischemic attack, systemic embolism, and/or major clinical bleeding was assessed. Patients with ESRD were compared with propensity score‐matched patients without severe CKD. ESRD was defined as a glomerular filtration rate < 15 ml/min/1.73 m 2 or chronic hemodialysis treatment. Results A total of 604 patients were analyzed, including 57 with ESRD and 57 propensity‐matched patients. Overall, 596 endocardial and 8 epicardial LAAC procedures were performed. Frequency of major complications was 7.0% (42/604 patients) in the overall cohort, 8.8% (5/57 patients) in patients with ESRD, and 10.5% (6/57 patients) in matched controls ( p = 0.75). The estimated event‐free survival of the combined endpoint after 500 days was 90.7 ± 4.5% in patients with ESRD and 90.2 ± 5.5% in matched controls ( p = 0.33). Conclusions LAAC had comparable procedural safety and clinical efficacy in patients with ESRD and patients without severe CKD.