Long-term outcomes of successful left atrial appendage occlusion with focus on stroke prevention: 10-year follow-up of a single-center registry

Abstract

Background: Percutaneous left atrial appendage occlusion (LAAO) is an alternative to anticoagulation in the prevention of stroke in patients with nonvalvular atrial fibrillation, especially in patients with a contraindication for oral anticoagulation therapy (OAT).

Objective: The study sought to obtain long-term patient outcomes after successful LAAO in everyday clinical practice.

Methods: In this single-center registry spanning over 10 years, data of all consecutive patients that underwent percutaneous LAAO were collected. Observed thromboembolic and major bleeding event rates after successful LAAO during follow-up were compared with expected event rates based on CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) and HAS-BLED (hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) scores. Furthermore, anticoagulation and antiplatelet use during follow-up was evaluated.

Results: Of 230 patients scheduled for LAAO (38% women, 69.5 ± 8.2 years of age, CHA₂DS₂-VASc score 3.9 ± 1.6, HAS-BLED score 2.9 ± 1.0), 218 patients had a successful implantation (95%) with a follow-up duration of 5.2 ± 3.1 years. The procedure was combined with catheter ablation in 52% of the patients. Fifty thromboembolic complications (24 ischemic stroke, 26 transient ischemic attack) were observed during follow-up in 40 (18%) of 218 patients. Ischemic strokes occurred with a rate of 2.1 per 100 patient-years, accounting for a 66% relative risk reduction compared with the CHA₂DS₂-VASc predicted event rate. Device-related thrombus was observed in 5 (2%) patients. Sixty-five nonprocedural major bleeding complications occurred in 24 (11%) of 218 patients with a rate of 5.7 per 100-patient years, which is comparable to estimated HAS-BLED-bleeding rates under OAT use. At end of follow-up 71% of all patients were on single antiplatelet or no antiplatelet or anticoagulation treatment, while 29% were on OAT.

Conclusion: Thromboembolic event rates during long-term follow-up after successful LAAO remained consistently lower than expected supporting the efficacy of LAAO.

Keywords: Atrial appendage; Atrial fibrillation; Cerebrovascular accident; Left atrial appendage occlusion; Stroke; Thromboembolism.

Figure 1

Flow chart of the study. FU = follow-up; LAA = left atrial appendage; LAAO = left atrial appendage occlusion.

Figure 2

Thromboembolic and major bleeding events during long-term follow-up (FU). A: Observed thromboembolic event rates compared with expected event rates without any anticoagulation therapy based on the CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score. B: Kaplan-Meier curve time to first ischemic stroke C: Annualized ischemic-stroke rate per FU year. D: Observed major bleeding event rates compared with expected event rates under anticoagulation use based on the HAS-BLED (hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) score. E: Kaplan-Meier curve major bleeding for the full cohort. F: Annualized major bleeding rate per FU year. HHT = hereditary hemorrhagic telangiectasia; RRR = relative risk reduction; SE = systemic embolism; TIA = transient ischemic attack.

Figure 3

Stand-alone left atrial appendage occlusion (LAAO) vs LAAO combined with catheter ablation (CA). A: Observed thrombo-embolic event-rates compared to expected event-rates without any anticoagulation therapy based on the CHA₂DS₂-VASc score of LAAO standalone and LAAO combines with CA cohorts. B: Kaplan meier curve time-to first stroke compared between LAAO standalone and LAAO combined with CA cohorts. C: Kaplan meier curve time-to first major bleeding compared between LAAO standalone and LAAO combined with CA cohorts. CHA₂DS₂-VASc = congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category; RRR = relative risk reduction.

Figure 4

Anticoagulation and antiplatelet use during the study. ∗Combined with low-molecular-weight heparin (∼2 weeks). DAPT = dual antiplatelet therapy, FU = follow-up; (N)OAC = (non–vitamin K) oral anticoagulation, SAPT = single antiplatelet therapy.