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Short-term antiplatelet versus anticoagulant therapy after left atrial appendage closure: a systematic review and meta-analysis

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Abstract

This meta-analysis compared the efficacy and safety of different antithrombotic regimens after left atrial appendage closure (LAAC). PubMed, Embase, Medline, Cochrane Library databases were systematically searched from their inception to March 2023. Patients were divided into short-term oral anticoagulation (OAC) group and antiplatelet therapy (APT) group. The incidence of events were performed using RevMan 5.4. The events including device-related thrombus (DRT), ischemic stroke/systemic embolization (SE), major bleeding, any bleeding, any major adverse event and all-cause mortality. Subgroup analysis were based on OAC alone or OAC plus single antiplatelet therapy (SAPT) in OAC group. Oral anticoagulants include warfarin and direct oral anticoagulant (DOAC). Fourteen studies with 35,166 patients were included. We found that the incidence of DRT (OR = 0.49, 95% CI 0.36–0.66, P＜0.0001) and all-cause mortality (OR = 0.71, 95% CI 0.57–0.89, P = 0.002) were significantly lower in OAC group than APT group. However, there was no statistical differences in the incidence rates of ischemic stroke/SE (OR = 0.77, 95% CI 0.49–1.20, P = 0.25), major bleeding (OR = 0.84, 95% CI 0.55–1.27, P = 0.84), any bleeding (OR = 0.83, 95% CI 0.56–1.22, P = 0.34) and any major adverse event (OR = 0.56, 95% CI 0.30–1.03, P = 0.06) in the two groups. Subgroup analysis found that the incidence of DRT, all-cause mortality and any major adverse event in OAC monotherapy were lower than that in APT group (P＜0.05), but not statistically different from other outcome. The incidence of DRT, all-cause mortality, any major adverse event and any bleeding in DOAC were significantly better than APT group (P＜0.05). While warfarin only has better incidence of DRT than APT (P＜0.05), there was no statistical difference between the two groups in other outcome (P＞0.05). The incidence of DRT was significantly lower than APT group (P＜0.05), major bleeding were higher, and the rest of the outcome did not show any statistically significant differences(P＞0.05) when OAC plus SAPT. Based on the existing data, short-term OAC may be favored over APT for patients who undergo LAAC. DOAC monotherapy may be favored over warfarin monotherapy or OAC plus APT, when selecting anticoagulant therapies.

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References

  1. Hindricks G, Potpara T, Dagres N et al (2021) 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 42(5):373–498

    PubMed  Google Scholar 

  2. Ogilvie IM, Newton N, Welner Sharon A et al (2010) Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 123(7):638–645

    CAS  PubMed  Google Scholar 

  3. Kong B, Liu Y, Huang H et al (2015) Left atrial appendage closure for thromboembolism prevention in patients with atrial fibrillation: advances and perspectives. J Thorac Dis 7(2):199–203

    PubMed  PubMed Central  Google Scholar 

  4. January CT, Wann LS, Calkins H et al (2019) 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS Guideline for the management of patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice guidelines and the heart rhythm society in collaboration with the Society of thoracic surgeons. Circulation 140(2):e125–151

    PubMed  Google Scholar 

  5. Osmancik P, Herman D, Neuzil P et al (2022) 4-Year outcomes after left atrial appendage Closure Versus nonwarfarin oral anticoagulation for Atrial Fibrillation. J Am Coll Cardiol 79(1):1–14

    PubMed  Google Scholar 

  6. Sedaghat A, Vij V, Al-Kassou B et al (2021) Device-related thrombus after left atrial appendage closure: data on thrombus characteristics, treatment strategies, and clinical outcomes from the EUROC-DRT-Registry. Circulation 14(5):e010195

    PubMed  Google Scholar 

  7. Chinese society of cardiology of Chinese medical association, editorial board of Chinese journal of cardiology (2019) 2019 Chinese Society of Cardiology (CSC) expert consensus statement on left atrial appendage closure in the prevention of Stroke in patients with atrial fibrillation. Zhonghua Xin xue guan bing za zhi 47(12):937–955

    Google Scholar 

  8. Nogami A, Kurita T, Kusano K et al (2022) JCS/JHRS 2021 Guideline focused update on Non-pharmacotherapy of Cardiac Arrhythmias. Circ J 86(2):337–363

    PubMed  Google Scholar 

  9. Faroux L, Cruz-González I, Arzamendi D et al (2021) Short-term direct oral anticoagulation or dual antiplatelet therapy following left atrial appendage closure in patients with relative contraindications to chronic anticoagulation therapy. Int J Cardiol 333:77–82

    PubMed  Google Scholar 

  10. Søndergaard L, Wong YH, Reddy VY et al (2019) Propensity-matched comparison of oral anticoagulation versus antiplatelet therapy after left atrial appendage closure With WATCHMAN. JACC Cardiovasc Interv 12(11):1055–1063

    PubMed  Google Scholar 

  11. Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62:e1–34

    PubMed  Google Scholar 

  12. Higgins JP, Altman DG, Gøtzsche PC et al (2011) The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928

    PubMed  PubMed Central  Google Scholar 

  13. Wells G, Shea B, O’Connell D et al The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Online]. Ottawa Hospital Research Institute Research Programs. Available at http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

  14. Su F, Gao C, Liu J et al (2022) Periprocedural outcomes Associated with Use of a left atrial appendage occlusion device in China. JAMA Netw Open 5(5):e2214594

    PubMed  PubMed Central  Google Scholar 

  15. Freeman JV, Higgins AY, Wang Y et al (2022) Antithrombotic therapy after left atrial appendage occlusion in patients with Atrial Fibrillation. J Am Coll Cardiol 79(18):1785–1798

    CAS  PubMed  PubMed Central  Google Scholar 

  16. Ledwoch J, Staubach S, Akin I et al (2022) Anticoagulation versus antiplatelet therapy after percutaneous left atrial appendage closure-subanalysis from the multicenter LAARGE registry. J Interv Card Electrophysiol 64(2):489–496

    PubMed  Google Scholar 

  17. Mazzone P, Laricchia A, D’Angelo G et al (2021) Role of Different Antithrombotic Regimens after Percutaneous Left Atrial Appendage Occlusion: A Large Single Center Experience. J Clin Med 10(9):1959

    PubMed  PubMed Central  Google Scholar 

  18. Cepas-Guillen PL, Flores-Umanzor E, Regueiro A et al (2021) Low Dose of Direct Oral Anticoagulants after Left Atrial Appendage Occlusion. J Cardiovasc Dev Dis 8(11):142

    CAS  PubMed  PubMed Central  Google Scholar 

  19. Duthoit G, Silvain J, Marijon E et al (2020) Reduced rivaroxaban dose versus dual antiplatelet therapy after left atrial appendage closure: ADRIFT a randomized pilot study. Circulation 13(7):e008481

    CAS  PubMed  Google Scholar 

  20. Asmarats L, O’Hara G, Champagne J et al (2020) Short-term oral anticoagulation versus antiplatelet therapy following transcatheter left atrial appendage closure. Circulation 13(8):e009039

    CAS  PubMed  Google Scholar 

  21. Ledwoch J, Sievert K, Boersma LVA et al (2020) Initial and long-term antithrombotic therapy after left atrial appendage closure with the WATCHMAN. Europace 22(7):1036–1043

    PubMed  Google Scholar 

  22. Liu XX, Kleinecke C, Busch S et al (2020) Propensity-matched comparison of antiplatelet versus anticoagulant after left atrial appendage closure with the Watchman. Pace 43(11):1242–1251

    PubMed  Google Scholar 

  23. Bergmann MW, Betts TR, Sievert H et al (2017) Safety and efficacy of early anticoagulation drug regimens after WATCHMAN left atrial appendage closure: three-month data from the EWOLUTION prospective, multicentre, monitored international WATCHMAN LAA closure registry. Eurointervention 13(7):877–884

    PubMed  Google Scholar 

  24. Tung MK, Ramkumar S, Cameron JD et al (2017) Retrospective cohort study examining reduced intensity and duration of anticoagulant and antiplatelet therapy following left atrial appendage occlusion with the WATCHMAN device. Heart Lung circ 26(5):477–485

    PubMed  Google Scholar 

  25. Bösche LI, Afshari F, Schöne D et al (2015) Initial experience with novel oral anticoagulants during the First 45 days after left atrial appendage Closure with the Watchman device. Clin Cardiol 38(12):720–724

    PubMed  PubMed Central  Google Scholar 

  26. Wiebe J, Franke J, Lehn K et al (2015) Percutaneous left atrial appendage closure with the watchman device: long-term results up to 5 years. JACC Cardiovasc Interv 8(15):1915–1921

    PubMed  Google Scholar 

  27. Saw J, Nielsen-Kudsk JE, Bergmann M et al (2019) Antithrombotic therapy and device-related thrombosis following endovascular left atrial appendage closure. JACC Cardiovasc Interv 12(11):1067–1076

    PubMed  Google Scholar 

  28. Rodés-Cabau J, O’Hara G, Paradis JM et al (2017) Changes in coagulation and platelet activation markers following transcatheter left Atrial Appendage Closure. Am J Cardiol 120(1):87–91

    PubMed  Google Scholar 

  29. Schwartz RS, Holmes DR, Van Tassel RA et al (2010) Left atrial appendage obliteration: mechanisms of healing and intracardiac integration. JACC Cardiovasc Interv 3(8):870–877

    PubMed  Google Scholar 

  30. Fauchier L, Cinaud A, Brigadeau F et al (2018) Device-related Thrombosis after percutaneous left atrial appendage occlusion for Atrial Fibrillation. J Am Coll Cardiol 71(14):1528–1536

    PubMed  Google Scholar 

  31. Holmes DR, Reddy VY, Turi ZG et al (2009) Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of Stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 374(9689):534–542

    CAS  PubMed  Google Scholar 

  32. Mesnier J, Cepas-Guillén P, Freixa X et al (2023) Antithrombotic management after left atrial appendage closure: current evidence and future perspectives. Circulation 16(5):e012812

    PubMed  Google Scholar 

  33. Li SY, Wang J, Hui X et al (2020) Meta-analysis of postoperative antithrombotic therapy after left atrial appendage occlusion. J Int Med Res 48(11):300060520966478

    PubMed  Google Scholar 

  34. Osman M, Busu T, Osman K et al (2020) Short-term antiplatelet versus anticoagulant therapy after left atrial appendage occlusion: a systematic review and meta-analysis. Clin Electrophysiol 6(5):494–506

    Google Scholar 

  35. Prasad RM, Al-Abcha A, Radwan Y et al (2021) Meta-analysis comparing antiplatelet therapy Versus Direct oral anticoagulation in Percutaneous Left Atrial Appendage Closure. Am J Cardiol 153:144–146

    CAS  PubMed  Google Scholar 

  36. Peternel P, Terbizan M, Tratar G et al (2002) Markers of hemostatic system activation during treatment of deep vein Thrombosis with subcutaneous unfractionated or low-molecular weight heparin. Thromb Res 105(3):241–246

    CAS  PubMed  Google Scholar 

  37. Amirtabar A, Vazquez SR, Saunders J et al (2023) Antiplatelet therapy indication in patients also prescribed direct oral anticoagulants. J Thromb Thrombolys 55(1):185–188

    CAS  Google Scholar 

  38. Angiolillo DJ, Bhatt DL, Cannon CP et al (2021) Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention: a north American perspective: 2021 update. Circulation 143(6):583–596

    CAS  PubMed  Google Scholar 

  39. Ge H, Zhang C, Qiao ZQ et al (2022) Risk of device-related Thrombosis following short-term oral anticoagulation with low-dose dabigatran versus warfarin after Watchman left atrial appendage occlusion. Sci Prog 105(3):1–14

    Google Scholar 

  40. Li X, Zhang X, Jin Q et al (2021) Clinical efficacy and safety comparison of Rivaroxaban and Dabigatran for Nonvalvular Atrial Fibrillation patients undergoing Percutaneous Left Atrial Appendage Closure Operation. Front Pharmacol 12:614762

    CAS  PubMed  PubMed Central  Google Scholar 

  41. Della Rocca DG, Magnocavallo M, Di Biase L et al (2021) Half-dose direct oral anticoagulation versus standard antithrombotic therapy after left atrial appendage occlusion. Cardiovasc Interv 14(21):2353–2364

    Google Scholar 

  42. Della Rocca DG, Horton RP, Di Biase L et al (2021) Incidence of device-related thrombosis in watchman patients undergoing a genotype-guided antithrombotic strategy. Clin Electrophysiol 7(12):1533–1543

    Google Scholar 

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Acknowledgements

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Funding

This study was supported by the grants from the National Natural Science Foundation of China (61905280, 82104303).

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Author notes

  1. Qiang Zhou and Xiang Liu contributed equally to this work and are co-first authors.

Authors and Affiliations

  1. Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China

    Qiang Zhou, Xiao-hui Huang, Yan-zi Wu, Ying-ying Tao & Meng Wei

  2. Department of Pharmacy and Traditional Chinese Pharmacy, Jiangsu College of Nursing, Huaian, China

    Xiang Liu

  3. Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Zhi-Chun Gu

  4. Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China

    Xian Yang

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Contributions

QZ and XL were involved in the study conception and design. QZ, XL, CZG and XY performed statistical analysis. MW, CZG and ZYW critically revised original study design and the manuscript. QZ, MW, YYT, HXH and XL contributed to the data acquisition, analysis, and interpretation. All authors have read and approved the final manuscript.

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Correspondence to Meng Wei.

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Zhou, Q., Liu, X., Gu, ZC. et al. Short-term antiplatelet versus anticoagulant therapy after left atrial appendage closure: a systematic review and meta-analysis. J Thromb Thrombolysis 57, 194–203 (2024). https://doi.org/10.1007/s11239-023-02919-2

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