Optimal Anticoagulation Strategy after Atrial Fibrillation Ablation in Patients with Prior Left Atrial Appendage Closure
Authors: Al-Shammari Ali Saad , Tariq Hamza , Ibrahim Ahmed , Taha Amira Mohamed , Abbas Ameer Fadhel , Ibrahim Ammar Sattar , Hado Mohammed , Narayanan Chockalingam , Sabayon Muhie Dean , Al-tai Haider 
Published: March 2024

Background: A significant knowledge gap exists in the optimal
anticoagulation strategy for patients with a history of left atrial
appendage (LAA) closure undergoing atrial fibrillation (AF) ablation.
The increasing prevalence of AF and the use of catheter-based AF
ablation (CA) and left atrial appendage closure (LAAC) highlight the
urgency of addressing this issue. Despite these developments, there is
no consensus on anticoagulation management for this specific patient
population. Non-valvular AF, the most common arrhythmia, carries a high
risk of stroke, systemic embolism (SE), heart failure (HF), and
mortality. Treatments like CA and LAAC are crucial in AF management.
LAAC, particularly, has shown noninferiority to traditional Vitamin K
antagonists (VKAs) and novel oral anticoagulants (NOACs) in stroke
prevention. However, the integration of CA and LAAC, often a one-stop
procedure, raises questions about optimal sequencing and anticoagulation
management, especially in patients at high bleeding risk or with a
history of thromboembolic or major bleeding incidents. Clinical
guidelines advise against discontinuing long-term oral anticoagulation
in high-stroke-risk patients post-CA. Alternative approaches, like LAAC
with devices like Watchman, offer options for patients accepting
procedural risks. Studies, including data from EVOLUTION and WASP
registries, demonstrate the effectiveness of combining CA and LAAC in
reducing stroke and late bleeding events. A retrospective observational
study also highlighted the efficacy of thoracoscopic LAA occlusion in
ischemic stroke prevention, with post-procedure reintroduction of OACs.
However, practices vary widely, with some patients receiving warfarin or
NOACs post-procedure, and others on dual antiplatelet therapy. Despite
these insights, research on anticoagulation management post-AF ablation
and LAA closure remains limited. This lack of comprehensive data is a
significant barrier to forming evidence-based guidelines for this
patient group. To address this gap, we propose a randomized controlled
trial (RCT) to investigate the optimal duration of post-AF ablation
anticoagulation in patients with a history of LAA closure. This RCT,
utilizing the PICO framework, would explore different anticoagulant
strategies versus no anticoagulation. Primary outcomes would include
thromboembolic events, bleeding complications, and overall
thromboembolic risk management. The RCT would involve a large cohort of
patients with a history of LAA closure post-AF ablation. The
intervention group would receive specific anticoagulant strategies
post-combined ablation and closure procedure, compared with a control
group on different anticoagulation approaches or no anticoagulation.
Efficacy and safety measures would be the primary focus, offering a
detailed understanding of the risks and benefits associated with each
anticoagulant strategy. Conclusion: The current lack of consensus on
anticoagulation strategies in patients post-LAA closure and AF ablation
necessitates dedicated research. An RCT focusing on these patients could
fill this critical knowledge gap, potentially leading to evidence-based
guidelines for their management. We recommend the initiation of an RCT
to comprehensively address this knowledge gap, aiming to establish
evidence-based guidelines for the management of these patients.