Discontinuation of antithrombotic management following left atrial appendage occlusion in high bleeding risk patients

Abstract Background Left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulation in patients with non-valvular atrial fibrillation. Anti-thrombotic therapy is required after implantation until the device is completely endothelialized. Whether longer-term antiplatelet agents are valuable is uncertain.1 Aims We studied the efficacy of LAAO in stroke prevention in patients with non-valvular atrial fibrillation, who were routinely given antiplatelet agents for six months only. Methods All patients with LAAO done from July 2009 to Jan 2024 were reviewed. Patients with successful implants and discharged with six months or less post-procedural antithrombotic regimen were recruited. The primary outcome of interest was the incidence of cerebrovascular events during follow-up. Secondary outcomes were the incidence of major bleeding, cardiovascular death and all-cause death. Results 259 patients underwent LAAO in the study period. A total of 128 patients put on six months or less post-procedural antithrombotic regimen were recruited and analyzed. 1 (0.8%) patient was lost to follow-up. Follow-up was obtained for 484 patient-years (median follow-up time of 3.6 years). 106 (82.8%) patients suffered from a previous bleeding event with or without oral anticoagulants. 78 (60.9%) patients had had a prior stroke. The median CHA2DS2-VASc score was 4 (3-5) while the median HAS-BLED score was 3 (3-4). Complete closure of left atrial appendage was achieved in 116 (90.6%) patients with no peri-device leak. After the LAAO procedure, 51 (39.8%) patients had 1 month of dual antiplatelet followed by 5 months of single antiplatelet therapy. 75 (58.6%) patients were put on 6 months or less of single antiplatelet therapy. During follow-up the primary outcome occurred in 5.5% of patients (1.45 per 100 patient-years), representing a 69% risk reduction adjusted to CHA2DS2-VASc. 10.2% of patients suffered from major bleeding (2.69 per 100 patient-years), representing a 49% risk reduction adjusted to HAS-BLED. 36.7% (9.71 per 100 patient-years) of patients died. In 4.7% (1.24 per 100 patient-years) of patients, the death was attributable to cardiovascular causes. Conclusion Complete cessation of antiplatelet treatment six months after LAAO is possible. The stroke rate during follow-up was 69% reduced adjusted to CHA2DS2-VASc. The bleeding rate was 49% reduced adjusted to HAS-BLED. Withdrawal of antiplatelet treatment at six months offers reduced bleeding risk longer term without an increased risk of stroke.Table of incidence of clinical outcomes Figure showing risk reduction