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