Resident physician Université de Montréal Montréal, Quebec, Canada
Background: While randomized controlled trials have demonstrated the efficacy of percutaneous left atrial appendage occlusion (pLAAO) in preventing stroke among patients with atrial fibrillation (AF), real-world adoption of the procedure often targets a distinct and more vulnerable population. In clinical practice, pLAAO is frequently performed on frail, elderly patients with multiple comorbidities and a history of major bleeding, often as a last-resort intervention when long-term oral anticoagulation (OAC) is no longer viable. This discrepancy between trial populations and real-world recipients highlights the need for observational data to guide clinical decision-making in this high-risk group, particularly regarding patient selection and post-procedural antithrombotic regimens.
METHODS AND RESULTS: This retrospective single-center study analyzed 285 patients who underwent pLAAO at the Centre hospitalier de l’Université de Montréal (CHUM) from 2011 to 2023. Patients were included if they had non-valvular AF and no other indication for systemic anticoagulation. The cohort had a mean age of 73.8 ± 8.0 years and was characterized by a significant comorbidity burden: hypertension (78.6%), dyslipidemia (63.2%), diabetes (37.9%). Patients were largely referred because of previous bleeding requiring hospitalization (93.3%). The median CHA₂DS₂-VASc and HAS-BLED scores were 4, indicating high risk of both thromboembolism and bleeding. Post-procedural antithrombotic regimens varied: 61.8% received dual antiplatelet therapy (DAPT), 21.4% single antiplatelet therapy (SAPT), 15.1% anticoagulation, and 1.8% no therapy. At the time of follow-up transoesophageal assessment (median 113 days), most patients transitioned to SAPT (72.8%), with 12.0% on DAPT, 14.1% no therapy and only 1.1% on anticoagulation. Procedural complications occurred in 14% of cases: 6.7% vascular, 6.7% pericardial effusions requiring drainage, and < 1% device embolization, stroke and death. The complication rate declined over time, likely reflecting improved operator proficiency with increased procedural experience and better patient selection. All-cause one-year mortality was 11.3%, largely driven by the no therapy subgroup (30.0%). The rate of readmissions for thromboembolism at one year was 3.5% and similar across groups (p = 0.952). The bleeding rate at one year was 2.1%, driven by the anticoagulation group (33.3% vs SAPT 2.4%, DAPT 0% and no treatment 0%, p = 0.001).
Conclusion: In a real-world setting, pLAAO was most used in frail, high-risk patients. Outcomes reflect this population’s vulnerability, with higher complication and mortality rates than those in controlled trials. Our data suggest both anticoagulation and no anticoagulation are potential drivers of bleeding and mortality, respectively, emphasizing the need for evidence-based guidance. In the interim, careful patient and antithrombotic regimen selection are paramount.
