Management Strategies to Prevent Stroke in Patients with Atrial Fibrillation and Malignant Left Atrial Appendage

Abstract

BackgroundPatients with atrial fibrillation (AF) and malignant left atrial appendage (LAA) may benefit from LAA closure (LAAC); however, evidence is limited. ObjectiveTo determine management strategies and clinical outcomes in patients with AF and malignant LAA. MethodsMalignant LAA was defined as ischemic stroke or LAA thrombus formation despite continuous oral anticoagulation (OAC) therapy (continuous for ≥3 weeks). We studied 80 patients with malignant LAA treated with LAAC. We compared these patients first against 44 patients with malignant LAA treated with OAC alone, and second against 114 patients without malignant LAA who were treated with LAAC for conventional indications. ResultsIn patients with malignant LAA (first-comparison), patients treated with LAAC had a higher 1-year cumulative incidence of ischemic stroke than patients treated with OAC alone (6.3% vs. 5.3%, log-rank P=0.09) whereas, the difference in stroke risk while receiving OAC was comparable (2.7% vs. 5.3%, log-rank P=0.84). Furthermore, all disabling stroke events among patients with malignant LAA treated with LAAC occurred only while not receiving OAC. In patients treated with LAAC (second-comparison), those with malignant LAA had a higher 1-year cumulative incidence of ischemic stroke (and ischemic stroke due to device-related thrombosis) than patients without malignant LAA (6.3% vs. 2.2%, log-rank P=0.009; 2.2% vs. 0%; log-rank P=0.04, respectively). However, these differences in stroke risk were no longer significant while receiving OAC (2.7% vs. 1.0%, log-rank P=0.11). ConclusionsBoth performing LAAC and continuation of OAC may be options to prevent ischemic stroke in patients with high thromboembolic risk and malignant LAA.