Left atrial appendage closure in patients with chronic kidney disease: results from the German multicentre LAARGE registry

Christian Fastner,Hüseyin Ince,Christian Weiß,Horst Sievert,Steffen Schneider,Ibrahim Akin,Johannes Brachmann,Holger H Sigusch,Uwe Zeymer,Jochen Senges,Matthias Hochadel,Thorsten Lewalter,Christoph A Nienaber,Sven T Pleger,Jens Maier,Stephan Achenbach,Martin Borggrefe

doi:10.1007/s00392-020-01638-5

Abstract

ObjectivesChronic kidney disease (CKD) is associated with an increased complication rate after cardiac interventions. Although CKD has a high prevalence among atrial fibrillation patients, the impact of CKD on periprocedural complications and the outcome after an interventional left atrial appendage closure (LAAC) is unclear. The present study, therefore, aimed to investigate whether CKD influences the procedure’s effectiveness and safety.MethodsLAARGE is a prospective, non-randomised registry. LAAC was conducted with different standard commercial devices, and the follow-up period was one year. CKD was defined by an eGFR < 60 mL/min/1.73 m2, and subgroups were further analysed (i.e. eGFR < 15, 15–29, and 30–59 mL/min/1.73 m2, respectively).ResultsTwo hundred ninety-nine of 623 patients (48.0%) revealed a CKD. The prevalence of cardiovascular comorbidity, CHA2DS2-VASc score (4.9 vs. 4.2), and HAS-BLED score (4.3 vs. 3.5) was significantly higher in CKD patients (each p < 0.001). Implantation success was similarly high across all GFR groups (97.9%). Periprocedural MACCE (0.7 vs. 0.3%), and other major complications (4.7 vs. 3.7%) were comparably infrequent. Survival free of stroke was significantly lower among CKD patients within 1 year (82.0 vs. 93.0%; p < 0.001; consistent after adjustment for confounding factors), without significant accentuation in advanced CKD (i.e. eGFR < 30 mL/min/1.73 m2; p > 0.05 vs. eGFR 30–59 mL/min/1.73 m2). Non-fatal strokes were absolutely infrequent during follow-up (0 vs. 1.1%). Severe non-fatal bleedings were observed only among CKD patients (1.4 vs. 0%; p = 0.021).ConclusionsDespite an increased cardiovascular risk profile of CKD patients, device implantation was safe, and LAAC was associated with effective stroke prevention across all CKD stages.

Highlights

Electronic supplementary material The online version of this article contains supplementary material, which is available to authorized users.Extended author information available on the last page of the articleStroke and systemic embolisation are prognostically relevant complications of atrial fibrillation (AF) [1]
The use of non-vitamin K antagonist oral anticoagulants (NOAC) should be avoided in patients with severely impaired renal function, i.e. estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m2, because insufficient data are available, and warfarin use is associated with conflicting outcome results [1]
Participating centres could document more than one indication for left atrial appendage closure (LAAC) in the same patient (Table 1)

Summary

Introduction

Clinical Research in Cardiology (2021) 110:12–20 is the recommended standard for prophylaxis in patients with non-valvular AF and a high thromboembolic risk [1], some patients reveal contraindications for a long-term use of such substances [3, 4]. For these patients, the left atrial appendage closure (LAAC) has evolved as an interventional alternative and was proven to be effective and safe in high-risk patients even without a post-procedural period with continued anticoagulation [1, 5]. The use of NOACs should be avoided in patients with severely impaired renal function, i.e. eGFR < 15 mL/min/1.73 m2, because insufficient data are available, and warfarin use is associated with conflicting outcome results [1]

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