Eitel, Ingo

Abstract Aims Patients with end-stage renal disease (ESRD) and atrial fibrillation present a challenge for thromboembolic prevention, given their elevated risks of both thromboembolism and bleeding. Anticoagulants carry a higher bleeding risk in this population without clear evidence of thromboembolic benefit. This study aims to define the role of left atrial appendage occlusion (LAAO) as a preventive strategy for patients with ESRD. Methods and results A systematic literature review was conducted to identify studies reporting outcomes in patients with ESRD who underwent LAAO. Meta-analyses of aggregate and individual patient data were performed to evaluate acute and long-term outcomes and compare them with those of patients without ESRD. Seventeen studies reporting data from 24 127 patients, including 1047 with ESRD, were included. Procedural complications were more common in patients with ESRD (RR 2.23; P = 0.02), with a pooled rate of 4% (95% CI, 1–9%). There was no significant difference in thromboembolic event rates during follow-up between the groups (IRR 1.44; P = 0.16), but major bleeding incidence was higher among patients with ESRD (IRR 1.84; P < 0.01). Individual patient-level data from seven studies comprising 4745 patients (268 with ESRD) were obtained and analysed. Similarly, there was no significant association between ESRD and stroke/TIA incidence (HR, 1.22; 95% CI, 0.66–2.26), but major bleeding was higher on patients with ESRD (HR, 1.65; 95% CI, 1.01–2.69). Conclusion LAAO represents a feasible option for thromboembolic prevention in patients with ESRD, although these patients have an increased risk of complications and bleeding.

ImportancePatients 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.ObjectiveTo 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 ParticipantsThis 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.ExposureLeft atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group).Main Outcomes and MeasuresThe primary outcome was time to first ischemic stroke.ResultsFour 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 < .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 RelevanceIn 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.