Clinical Outcomes of Left Atrial Appendage Occlusion Versus Switch of Direct Oral Anti-coagulant in Atrial Fibrillation

Background Left atrial appendage occlusion (LAAO) has emerged as an alternative to oral anti-coagulation therapy for stroke prevention in atrial fibrillation (AF), but data comparing LAAO with direct oral anti-coagulant (DOAC) is sparse. Method This cohort study compared LAAO (with or without prior anti-coagulation) with a switch of one DOAC to another DOAC. The primary outcome was a composite of all-cause mortality, ischemic stroke and major bleeding. Results A total of 2,350 patients (874 in the LAAO group and 1,476 in the DOAC switch group) were generated by 1:2 propensity score matching. After a mean follow up of 1052 ± 694 days, the primary outcome developed in 215 (24.6%) patients in the LAAO group and in 335 (22.7%) patients in the DOAC switch group (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.80 to 1.12; P=0.516). The LAAO group had a lower all-cause mortality (HR, 0.49; 95% CI, 0.39 to 0.60; P<0.001) and cardiovascular mortality (HR, 0.49; 95% CI, 0.32 to 0.73; P<0.001), but similar risk of ischemic stroke (HR, 0.83; 95% CI, 0.63 to 1.10; P=0.194). The major bleeding risk was similar overall (HR, 1.18; 95% CI, 0.94 to 1.48, P=0.150), but was lower in the LAAO group after 6 months (HR 0.71; 95% CI 0.51 to 0.97; P=0.032). Conclusions LAAO conferred a similar risk of composite outcome of all-cause mortality, ischemic stroke and major bleeding, as compared with DOAC switch. The risks of all-cause mortality and cardiovascular mortality were lower with LAAO. CLINICAL PERSPECTIVE 1) What Is New? Data comparing left atrial appendage occlusion (LAAO) with direct oral anti-coagulant (DOAC) in patient with atrial fibrillation (AF) was sparse. LAAO conferred a similar risk of composite outcome of all-cause mortality, ischemic stroke and major bleeding, as compared with switch of DOAC in patients with AF and intolerant to at least one anti-coagulant. The risks of all-cause mortality and cardiovascular mortality were halved with LAAO. 2) What Are the Clinical Implications? This study highlights the potential role of LAAO as a superior alternative to trying another DOAC for patients with AF and intolerant to at least one DOAC. Bleeding events after 6 months post LAAO were significantly reduced by 30% in the LAAO group as compared with the DOAC switch group, coinciding with the de-escalation in anti-thrombotic therapy. Reduction in bleeding during the first 6 months post LAAO represents a potential opportunity to further improve outcomes after LAAO.