Left Atrial Appendage Occlusion vs Standard of Care After Ischemic Stroke Despite Anticoagulation
Authors: Maarse Moniek , Seiffge David J. , Werring David J. , Boersma Lucas V. A. ,   STR-OAC LAAO Group, Macha Kosmas , Takagi Masahito , Tsivgoulis Georgios , Bonetti Bruno , Arihiro Shoji , Alberti Andrea , Polymeris Alexandros , Ambler Gareth , Yoshimura Sohei , Venti Michele , Bonati Leo , Muir Keith , Yamagami Hiroshi , Thilemann Sebastian , Altavilla Riccardo , Peters Nils , Inoue Manabu , Bobinger Tobias , Agnelli Giancarlo , Brown Martin , Sato Shoichiro , Acciarresi Monica , Jager Hans , Bovi Paolo , Schwab Stefan , Lyrer Philippe , De Marchis Gian Marco , Peper Joyce , Simard Trevor , Alkhouli Mohamad ,   RAF, RAF-DOAC, CROMIS-2, SAMURAI, NOACISP, Erlangen Registry, and Verona Registry, Aarnink Errol W. , Fierro Nicolai , Mazzone Patrizio , Beneduce Alessandro , Tondo Claudio , Gasperetti Alessio , Pracon Radoslaw , Demkow, Marcin , Zieliński Kamil , de Backer Ole , Korsholm Kasper , Nielsen-Kudsk Jens Erik , Estévez-Loureiro Rodrigo , Caneiro-Queija Berenice , Benito-González Tomás , de Prado Armando Pérez , Nombela-Franco Luis , Salinas Pablo , Holmes David , Almakadma Abdul H. , Berti Sergio , Romeo Maria Rita , Alvarez Xavier Millan , Arzamendi Dabit , Alla Venkata M. , Agarwal Himanshu , Eitel Ingo , Paitazoglou Christina , Freixa Xavier , Cepas-Guillén Pedro , Chothia Rashaad , Badejoko Solomon O. , Bergmann Martin W. , Spoon Daniel B. , Maddux James T. , El-Chami Mikhael , Ram Pradhum , Branca Luca , Adamo Marianna , Suradi Hussam S. , van Dijk Vincent F. , Rensing Benno J. W. M. , Zietz Annaelle , Paciaroni Maurizio , Caso Valeria , Koga Masatoshi , Toyoda Kazunori , Kallmünzer Bernd , Cappellari Manuel , Wilson Duncan , Engelter Stefan , Swaans Martin J. 
Published: September 2024

Importance

Patients with atrial fibrillation (AF) who have ischemic stroke despite taking oral anticoagulation therapy (OAT) have a very high risk of recurrence. Left atrial appendage occlusion (LAAO) is a mechanical stroke prevention strategy that may provide additional protection in patients with thromboembolic events under OAT.

Objective

To compare percutaneous LAAO with continuing OAT alone regarding stroke prevention in patients with AF who had a thromboembolic event despite taking OAT.

Design, Setting, and Participants

This cohort study was a propensity score–matched comparison of the STR-OAC LAAO cohort, an international collaboration of 21 sites combining patients from multiple prospective registries of patients who underwent LAAO between 2010 and 2022. STR-OAC LAAO cohort patients who had follow-up longer than 3 months were propensity score–matched to a previously published control cohort comprising patients from an established international collaboration of investigator-initiated prospective studies. This control cohort included patients with nonvalvular AF, recent ischemic stroke or transient ischemic attack, and follow-up longer than 3 months who were taking OAT before the index event. Analyses were adjusted for imbalances in gender, age, hypertension, diabetes, and CHA2 DS2-VASc score.

Exposure

Left atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group).

Main Outcomes and Measures

The primary outcome was time to first ischemic stroke.

Results

Four hundred thirty-three patients from the STR-OAC LAAO cohort (mean [SD] age, 72 [9] years; 171 [39%] females and 262 [61%] males; mean [SD] CHA2 DS2-VASc score, 5.0 [1.6]) were matched to 433 of 1140 patients (38%) from the control group. During 2-year follow-up, 50 patients experienced ischemic stroke: an annualized event rate of 2.8% per patient-year in the STR-OAC LAAO group vs 8.9% per patient-year in the control group. Left atrial appendage occlusion was associated with a lower risk of ischemic stroke (hazard ratio, 0.33; 95% CI, 0.19-0.58; P &amp;lt; .001) compared with the control group. After LAAO, OAT was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued OAT after LAAO as an adjunctive therapy.

Conclusions and Relevance

In patients with nonvalvular AF and a prior thromboembolic event despite taking OAT, LAAO was associated with a lower risk of ischemic stroke compared with continued OAT alone. Randomized clinical trial data are needed to confirm that LAAO may be a promising treatment option for this population with a very high risk of stroke.