Left atrial appendage closure after anticoagulation failure: a promising hybrid strategy, but for whom?

Karol Wielgus; Agata Krawczyk‐Ożóg; Artur Dziewierz

doi:10.20452/pamw.17435

October 29, 2026Polskie Archiwum Medycyny WewnętrznejOpen Access

Left atrial appendage closure after anticoagulation failure: a promising hybrid strategy, but for whom?

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Why the study?

Does left atrial appendage closure followed by long-term anticoagulation reduce thromboembolic and bleeding events in atrial fibrillation patients with prior anticoagulation failure?

Key Points

To critically evaluate the clinical evidence, methodological limitations, and patient selection criteria for adding left atrial appendage closure to long-term anticoagulation following anticoagulation failure.
Commentary evaluating a multicenter Polish study assessing a hybrid strategy of left atrial appendage closure (LAAC) combined with anticoagulation in patients with atrial fibrillation and prior anticoagulation failure.
Methodological critique focused on secular confounding, between-group imbalances, stroke etiology adjudication, and the validity of risk score benchmarks.
Direct group comparisons showed no significant difference for stroke/transient ischemic attack/peripheral embolism (log-rank P=0.1; intention-to-treat P=0.11; 1 vs 10 events) or major bleeding (P=0.27; 0 vs 3 events) between hybrid and nonhybrid cohorts.
Hybrid-strategy patients more frequently received newer-generation occluders (98.4% vs 68.8%; P<0.001) and had shorter follow-up (401 vs 555 d; P=0.04) than nonhybrid controls.
Device-related thrombus rates were 6.9% in the hybrid group versus 6.8% in the nonhybrid group.

Structured PICO

Does left atrial appendage closure followed by long-term anticoagulation reduce thromboembolic and bleeding events in atrial fibrillation patients with prior anticoagulation failure?

P

Population

Atrial fibrillation (AF) patients with prior anticoagulation failure treated at participating high-volume Polish centers

I

Intervention

Left atrial appendage closure (LAAC) followed by long-term anticoagulation (the 'hybrid strategy')

C

Comparator

Nonhybrid strategy (LAAC without long-term anticoagulation)

Limitations

Anticoagulation failure is a heterogeneous label rather than a single entity
Between-group contrast is vulnerable to selection bias and temporal confounding as the nonhybrid arm is largely historical
Limited sample size and low event counts prevented multivariable adjustment
Relative reductions calculated against CHA2DS2-VASc and HAS-BLED predicted rates likely misclassify true counterfactual risk
Unequal imaging and analysis of only the first scheduled study may have affected thrombus and leak detection

Implication

This letter highlights that while combining left atrial appendage closure with long-term anticoagulation for atrial fibrillation patients with prior anticoagulation failure is a promising hypothesis-generating concept, current observational data are limited by selection bias, temporal confounding, and nonsignificant direct event comparisons.

Abstract

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Cite This Study

Wielgus et al. (2026) studied this question.

synapsesocial.com/papers/6ae4c6aff5f953b5b4fb647e https://doi.org/10.20452/pamw.17435

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Left atrial appendage closure after anticoagulation failure: a promising hybrid strategy, but for whom?

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Left atrial appendage closure after anticoagulation failure: a promising hybrid strategy, but for whom?

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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