Prevalence of discussions around left atrial appendage occlusion as a treatment option in patients on oral anticoagulation experiencing a major bleeding event

Abstract

BackgroundGuidelines recommend considering percutaneous left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) at moderate to high stroke risk and contraindications to long-term anticoagulation. Discontinuation of anticoagulation in this patient population, without an alternative treatment option, may place patients at unnecessary risk. This study aimed to assess the prevalence of discussions around LAAO as a treatment option following major bleeding adverse events in patients on oral anticoagulation for AF and to identify the proportion of patients stopping anticoagulation without evidence of LAAO discussions. MethodsFrom a single, large medical center in the United States, patients on an oral anticoagulant for AF and having at least one major bleeding adverse event, defined by the International Society on Thrombosis and Haemostasis, between January 2015 and October 2023 were identified within a quality improvement registry. Information about LAAO discussions, subsequent procedures, and permanent discontinuation of anticoagulation was assessed using the Electronic Medical Record Search Engine and manual electronic medical record reviews. ResultsA total of 222 patients experienced major bleeding (54.5 % male, 86.9 % white, median age 77 years, 58.6 % on warfarin). From this group, 283 major bleeds were documented (44.2 % gastrointestinal, 17.7 % intracranial). LAAO discussions were documented in 51 patients (23 %), with LAAO procedures performed in 9 of these patients (17.6 %). After the major bleed, 54 (24.3 %) patients permanently stopped anticoagulation. Of these patients, 18 (33.3 %) had LAAO discussions prior to discontinuation and only 1 (1.9 %) had LAAO implantation. ConclusionsIn patients experiencing a major bleed, less than a quarter had documented discussions about LAAO and over a quarter permanently stopped anticoagulation.