Left atrial appendage occlusion for atrial fibrillation–related stroke despite chronic oral anticoagulation
L Giovachini, J Mesnier, T Pommier, G Ducrocq, M Zeitouni, L Faucheux, M Benamer, C Rosso, S Alamowitch, G Gerschenfeld, C Blanc, P Guedeney, G Montalescot, J SilvainAbstract
Background
Data on the benefit of percutaneous left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) who experience stroke despite chronic oral anticoagulation (OAC) are limited and not always consistent.
Aim
To evaluate the association between LAAO and recurrent stroke or mortality using a pre-post LAAO study design accounting for recurrent events, comparing event rates before and after LAAO, each patient serving as their own control.
Methods
In this retrospective cohort study from two tertiary French centers, only patients undergoing LAAO for AF-related stroke despite well conducted OAC were included. The primary outcome was incidence of the composite of recurrent ischemic stroke and/or all-cause death during follow-up. Ischemic stroke rates during the 5-year pre-procedure period were compared with primary outcome after LAAO until last follow-up using a quasi-Poisson regression model. This model analyzed the number of events over time while accounting for potential overdispersion (variance not equal to the incidence rate) and adjusting for individual exposure time through a patient-level offset.
Results
Between 2012 and 2024, 60 patients were included (median age 75 [71-83], male 61.7%]). Prior to LAAO, patients experienced 104 AF-related strokes (mean annualized incidence 0.37 [0.26-0.39] per patient). After LAAO and over a follow-up of 3.5[0.9-6.5] years, 18 recurrences of stroke and 17 deaths occurred (primary outcome mean annualized incidence 0.15[0.10-0.20] per patient). Using a quasi-Poisson regression model, LAAO was associated with a reduction of recurrent stroke or death (RR 0.46 (95% CI 0.24–0.85), p=0.01).
Conclusion
In this observational cohort of patients with AF-related stroke despite OAC, LAAO was associated with a marked reduction in recurrent stroke or death comparing pre and post-LAAO periods. Dedicated randomized controlled trials are warranted in this population.Graphical abstract