Abstract
Objective: Due to the clinical complexity of warfarin, novel oral anticoagulation (NOAC) has been a feasible and safe alternative anticoagulant approach during left atrial appendage closure (LAAC). This study was designed to compare the efficacy and safety of rivaroxaban and dabigatran for nonvalvular atrial fibrillation patients undergoing percutaneous LAAC. Methods: One single and prospective cohort study was performed among patients who received anticoagulation with dabigatran or rivaroxaban. All patients were medicated with a 3-month course of NOAC to facilitate device endothelialization, followed by dual antiplatelet therapy until 6 months, then lifelong aspirin after discharge. Repeated transesophageal echocardiography was scheduled to evaluate thrombosis formation on occluders and thrombus dissolution ability. Results: A total of 262 consecutive patients were initially enrolled. A final number of 250 patients were analyzed; two patients were excluded due to procedure failure and 10 patients had a loss of follow-up; 97 were from the dabigatran group and 153 from the rivaroxaban group. Three patients (1.9%) in the rivaroxaban group and eight (8.2%) in the dabigatran group were experiencing device-related thrombosis (DRT) events during follow-ups. Cumulative Kaplan–Meier estimates showed that the incidence of DRT was lower under rivaroxaban medication during the 6-month follow-ups (p = 0.038*, OR = 3.843, 95%CI: 0.991–14.836). The transesophageal echocardiography (TEE) results showed that the average length and width of DRT in the rivaroxaban group was significantly lower compared with that in the dabigatran group (2.16 vs. 1.60 mm, p = 0.017*, and 1.71 vs. 1.30 mm, p = 0.003*, respectively). The thrombosis dissolved after the switch from dabigatran or rivaroxaban to warfarin within the target range, represented by the average length and width of thrombus with the cooperation of secondary TEE for the dabigatran and rivaroxaban groups (0.64 vs. 0.40 mm, p = 0.206, and 0.43 vs. 0.27 mm, p = 0.082, respectively). No significant difference was found between the two groups with respect to the levels of coagulation parameters, cardiac function, and bleeding events. Conclusion: Compared to dabigatran, post-procedural rivaroxaban anticoagulation might be advantageous in preventing DRT complications expected after LAAC, without increasing the risk of hemorrhage.
Highlights
Compared to dabigatran, post-procedural rivaroxaban anticoagulation might be advantageous in preventing device-related thrombosis (DRT) complications expected after left atrial appendage closure (LAAC), without increasing the risk of hemorrhage
Percutaneous left atrial appendage closure (LAAC) has become an effective and safe surgical method for the prevention of stroke, mainly in patients diagnosed with nonvalvular atrial fibrillation (NVAF) and who could not adhere to long-term anticoagulant therapy (Reddy et al, 2013; Iskandar et al, 2016; Reddy, 2018)
The anticoagulants were switched from novel oral anticoagulants (NOACs) to warfarin within the therapeutic range (INR 2.0–3.0), and transesophageal echocardiography (TEE) was performed to identify the resolution of DRT after 3 months following anticoagulation
Summary
Percutaneous left atrial appendage closure (LAAC) has become an effective and safe surgical method for the prevention of stroke, mainly in patients diagnosed with nonvalvular atrial fibrillation (NVAF) and who could not adhere to long-term anticoagulant therapy (Reddy et al, 2013; Iskandar et al, 2016; Reddy, 2018). Due to the clinical complexity of warfarin, which has been suggested as a standard anticoagulant approach during LAAC, strong interest was developed in alternative therapies with novel oral anticoagulants (NOACs) in the peri- and post-procedural settings after occluder implantation (Enomoto et al, 2017). There was a significant interindividual variability on anticoagulation before complete endothelialization on the device, which might add to the uncertainty of the duration of antithrombotic therapy during this vulnerable time for DRT
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