Left atrial appendage occlusion in patients with atrial fibrillation and previous Intracranial Hemorrhage or Cerebral Amyloid Angiopathy: a systematic review and meta-analysis.
Theodoros Mavridis, Paraschos Archontakis Barakakis, David-Dimitris Chlorogiannis, Andreas CharidimouBackground:
Patients with atrial fibrillation (AF) on oral anticoagulation (OAC) who have a history of intracranial hemorrhage (ICrH) or cerebral amyloid angiopathy (CAA) have an elevated risk of ICrH recurrence. Left atrial appendage occlusion (LAAO) has emerged as a potential alternative to OAC for stroke prevention in high-bleeding-risk AF patients. Small observational studies suggest that LAAO may be safe and feasible in patients with ICrH, when using single or dual antiplatelet therapy or short-term OAC post-procedure, though data remain limited. This systematic review and meta-analysis aims to consolidate evidence on the safety and efficacy of LAAO in patients with prior ICrH or CAA.
Methods:
We conducted a systematic review and meta-analysis examining the safety and efficacy of LAAO in patients with non-valvular AF and prior ICrH and/or CAA. PubMed/MEDLINE and EMBASE (via Scopus) databases were systematically searched from inception until 29 February 2024. Eligible studies included randomized control trials, observational studies, and case series (≥10 participants) reporting stroke events in patients with AF and previous history of ICrH and/or CAA undergoing LAAO. Pooled incidence rates (IRs) with corresponding 95% confidence intervals (CIs) were calculated for primary outcomes (post-procedural ischemic stroke and recurrent ICrH) and secondary outcomes.
Results:
Fourteen studies including 1,235 patients met inclusion criteria. The pooled average follow-up period was 17.1 months. The pooled IRs for ischemic stroke, recurrent ICrH, and major hemorrhage were 2% (95%CI: 1%–3%, I2=2%), 2% (95%CI: 0.4%–3%, I2=45%) and 3% (95%CI: 1%–5%, I2=54%), respectively. In prespecified subgroup analyses of studies focusing on patients with intraparenchymal hemorrhage and/or CAA, pooled IRs for ischemic stroke, recurrent ICrH, and major hemorrhage IR of 4% (95%CI: 1%–8%), 4% (95%CI: 0.4%–10%) and 6% (95%CI: 3%–12%), respectively.
Conclusions:
LAAO may be a safe and effective treatment for selected AF patients with a history of ICrH and/or CAA, but the quality of evidence is poor. Future randomized controlled trials are essential to validate LAAO's efficacy and long-term safety.