Abstract 14588: Comparison of Different Antithrombotic Regimens After Left Atrial Appendage Occlusion: A Systematic Review and Network Meta-Analysis

Abstract

Background: The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) in patients with non-valvular atrial fibrillation (AF) remains uncertain, given the high-risk profile of this population. This network meta-analysis aimed to compare the efficacy and safety of various antithrombotic strategies after LAAO. Methods: We conducted a comprehensive search of MEDLINE, Cochrane, Embase, Lilacs, and ClinicalTrials.gov databases for studies that reported clinical outcomes after LAAO, categorized by the antithrombotic therapies administered at discharge. Direct oral anticoagulants (DOACs), vitamin-K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), DOAC plus SAPT, VKA plus SAPT, and no therapy were analyzed. We performed a frequentist random-effects network meta-analysis to estimate the odds ratio (OR) with 95% confidence intervals (CI) for each strategy. The surface under the cumulative ranking curve (SUCRA) P-scores provided a ranking of treatments. Quality assessment and risk of bias were conducted in accordance with Cochrane recommendations. Results: 39 observational studies and 1 clinical trial with a total of 11,111 patients with non-valvular AF were included, totaling 540 cardiovascular events. In the network comparison, DAPT (OR 0.35; 95% CI 0.16-0.76), DOAC (OR 0.35; 95% CI 0.13-0.94), DOAC plus SAPT (OR 0.17; 95% CI 0.04-0.74), and VKA (OR 0.34; 95% CI 0.12-0.97) were superior to no therapy to prevent device-related thrombosis (DRT), whereas SAPT (OR 0.46; 95% CI 0.21-1.03) and VKA plus SAPT (OR 0.43; 95% CI 0.10-0.87) were similar to no antithrombotic therapy. DOAC was associated with a significant reduction of all-cause mortality compared with VKA (OR 0.36; 95% CI 0.15-0.85) and a non-significant trend vs. SAPT (OR 0.49; 95% CI 0.22-1.11). Moreover, DAPT (OR 0.49; 95% CI 0.26-0.91) was superior to SAPT in reducing thromboembolic events, but similar to VKA (OR 0.88; 95% CI 0.37-2.37). There was no significant difference between therapies analyzed in the occurrence of major bleeding. Conclusion: In patients with nonvalvular AF undergoing LAAO, DOAC monotherapy is safe and reduce DRT, all-cause mortality, and thromboembolic events compared with other therapies.