Comparison of Antithrombotic Regimens after Left Atrial Appendage Occlusion: A Systematic Review and Network Meta-analysis

Abstract

Abstract Background The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) in patients with non-valvular atrial fibrillation (AF) remains uncertain. Purpose 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, and ClinicalTrials.gov databases for studies that reported outcomes after LAAO, stratified 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 antithrombotic therapy were analyzed. We performed a frequentist random-effects model 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 We included 39 studies comprising 10,573 patients with non-valvular AF. As shown in Figure 1, in the network comparison, DAPT (OR 0.33; 95% CI 0.14-0.73), DOAC (OR 0.31; 95% CI 0.11-0.84), DOAC plus SAPT (OR 0.15; 95% CI 0.03-0.68), and VKA (OR 0.29; 95% CI 0.10-0.87) were superior to no therapy in preventing device-related thrombosis (DRT). There was no significant difference between the therapies analyzed in terms of major bleeding (Figure 2). In the SUCRA analysis, DOAC plus SAPT had the highest probability of being the best strategy for preventing DRT, followed by VKA and DOAC monotherapies, respectively. DOAC monotherapy was associated with the lowest probability of major bleeding, followed by DOAC plus SAPT and VKA as monotherapy, respectively. Conclusion In patients with non-valvular AF undergoing LAAO, post-discharge therapy with DOAC as monotherapy reduces the incidence of DRT compared with no therapy and is associated with a lower probability of major bleeding compared with other therapies.Figure 1.DRTFigure 2.Major bleeding