Left Atrial Appendage Occlusion vs Standard of Care after Ischemic Stroke Despite Anticoagulation

Moniek Maarse; David J. Seiffge; David J. Werring; Lucas V. A. Boersma; Errol W. Aarnink; Nicolai Fierro; Patrizio Mazzone; Alessandro Beneduce; Claudio Tondo; Alessio Gasperetti; Radoslaw Pracon; Marcin Demkow,; Kamil Zieliński; Ole de Backer; Kasper Korsholm; Jens Erik Nielsen-Kudsk; Rodrigo Estévez-Loureiro; Berenice Caneiro-Queija; Tomás Benito-González; Armando P. rez de Prado; Luis Nombela-Franco; Pablo Salinas; David Holmes; Abdul H. Almakadma; Sergio Berti; Maria Rita Romeo; Xavier Millan Alvarez; Dabit Arzamendi; Venkata M. Alla; Himanshu Agarwal; Ingo Eitel; Christina Paitazoglou; Xavier Freixa; Pedro Cepas-Guillén; Rashaad Chothia; Solomon O. Badejoko; Martin W. Bergmann; Daniel B. Spoon; James T. Maddux; Mikhael el-Chami; Pradhum Ram; Luca Branca; Marianna Adamo; Hussam S. Suradi; Vincent F. van Dijk; Benno J. W. M. Rensing; Annaelle Zietz; Maurizio Paciaroni; Valeria Caso; Masatoshi Koga; Kazunori Toyoda; Bernd Kallmünzer; Manuel Cappellari; Duncan Wilson; Stefan Engelter; Martin J. Swaans

doi:10.1001/jamaneurol.2024.2882

Left Atrial Appendage Occlusion vs Standard of Care after Ischemic Stroke Despite Anticoagulation

Moniek Maarse
, David J. Seiffge
, David J. Werring
, Lucas V. A. Boersma^*
, Errol W. Aarnink
, Nicolai Fierro
, Patrizio Mazzone
, Alessandro Beneduce
, Claudio Tondo
, Alessio Gasperetti
, Radoslaw Pracon
, Marcin Demkow,
, Kamil Zieliński
, Ole de Backer
, Kasper Korsholm
, Jens Erik Nielsen-Kudsk
, Rodrigo Estévez-Loureiro
, Berenice Caneiro-Queija
, Tomás Benito-González
, Armando P. rez de Prado

Luis Nombela-Franco, Pablo Salinas, David Holmes, Abdul H. Almakadma, Sergio Berti, Maria Rita Romeo, Xavier Millan Alvarez, Dabit Arzamendi, Venkata M. Alla, Himanshu Agarwal, Ingo Eitel, Christina Paitazoglou, Xavier Freixa, Pedro Cepas-Guillén, Rashaad Chothia, Solomon O. Badejoko, Martin W. Bergmann, Daniel B. Spoon, James T. Maddux, Mikhael el-Chami, Pradhum Ram, Luca Branca, Marianna Adamo, Hussam S. Suradi, Vincent F. van Dijk, Benno J. W. M. Rensing, Annaelle Zietz, Maurizio Paciaroni, Valeria Caso, Masatoshi Koga, Kazunori Toyoda, Bernd Kallmünzer, Manuel Cappellari, Duncan Wilson, Stefan Engelter, Martin J. Swaans

^*Corresponding author for this work

St. Antonius Ziekenhuis
Amsterdam UMC - University of Amsterdam
University of Bern
University College London
Asst Grande Ospedale Metropolitano Niguarda
IRCCS Ospedale San Raffaele
IRCCS Centro Cardiologico S.P.A. Fondazione Monzino - Milano
University of Milan
Johns Hopkins University
Cardinal Stefan Wyszynski Institute of Cardiology
University of Copenhagen
Aarhus University
University Hospital Álvaro Cunqueiro
University Hospital of León
Hospital Clínico San Carlos de Madrid
Mayo Clinic Rochester, MN
Fondazione Toscana G. Monasterio
Research Institute of the Santa Creu i Sant Pau Hospital
Creighton University
University Heart Center Lübeck
German Centre for Cardiovascular Research
Hospital Clinic de Barcelona
St. Joseph's Medical Center, Stockton
Asklepios Klinik St. Georg
Providence Heart Institute
Emory University
University of Brescia
Rush University
University of Basel
University of Perugia
National Cerebral and Cardiovascular Center
Azienda Ospedaliera Universitaria Integrata Verona
Friedrich-Alexander University Erlangen-Nürnberg
Canterbury District Health Board
New Zealand Brain Research Institute

Research output: Contribution to journal › Article › Academic › peer-review

128 Downloads (Pure)

Abstract

Importance: Patients with atrial fibrillation (AF) who have ischemic stroke despite taking oral anticoagulation therapy (OAT) have a very high risk of recurrence. Left atrial appendage occlusion (LAAO) is a mechanical stroke prevention strategy that may provide additional protection in patients with thromboembolic events under OAT. Objective: To compare percutaneous LAAO with continuing OAT alone regarding stroke prevention in patients with AF who had a thromboembolic event despite taking OAT. Design, Setting, and Participants: This cohort study was a propensity score-matched comparison of the STR-OAC LAAO cohort, an international collaboration of 21 sites combining patients from multiple prospective registries of patients who underwent LAAO between 2010 and 2022. STR-OAC LAAO cohort patients who had follow-up longer than 3 months were propensity score-matched to a previously published control cohort comprising patients from an established international collaboration of investigator-initiated prospective studies. This control cohort included patients with nonvalvular AF, recent ischemic stroke or transient ischemic attack, and follow-up longer than 3 months who were taking OAT before the index event. Analyses were adjusted for imbalances in gender, age, hypertension, diabetes, and CHA2 DS2-VASc score. Exposure: Left atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group). Main Outcomes and Measures: The primary outcome was time to first ischemic stroke. Results: Four hundred thirty-three patients from the STR-OAC LAAO cohort (mean [SD] age, 72 [9] years; 171 [39%] females and 262 [61%] males; mean [SD] CHA2 DS2-VASc score, 5.0 [1.6]) were matched to 433 of 1140 patients (38%) from the control group. During 2-year follow-up, 50 patients experienced ischemic stroke: an annualized event rate of 2.8% per patient-year in the STR-OAC LAAO group vs 8.9% per patient-year in the control group. Left atrial appendage occlusion was associated with a lower risk of ischemic stroke (hazard ratio, 0.33; 95% CI, 0.19-0.58; P <.001) compared with the control group. After LAAO, OAT was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued OAT after LAAO as an adjunctive therapy. Conclusions and Relevance: In patients with nonvalvular AF and a prior thromboembolic event despite taking OAT, LAAO was associated with a lower risk of ischemic stroke compared with continued OAT alone. Randomized clinical trial data are needed to confirm that LAAO may be a promising treatment option for this population with a very high risk of stroke..

Original language	English
Journal	JAMA Neurology
Volume	81
Issue number	11
DOIs	https://doi.org/10.1001/jamaneurol.2024.2882
Publication status	Published - 11 Nov 2024

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Access to Document

10.1001/jamaneurol.2024.2882

Left-atrial-appendage-occlusion-vs-standard-of-care-after-ischemic-stroke-despite-anticoagulation.pdfFinal published version, 389 KBLicence: Taverne

Cite this

Maarse, M., Seiffge, D. J., Werring, D. J., Boersma, L. V. A., Aarnink, E. W., Fierro, N., Mazzone, P., Beneduce, A., Tondo, C., Gasperetti, A., Pracon, R., Demkow, M., Zieliński, K., de Backer, O., Korsholm, K., Nielsen-Kudsk, J. E., Estévez-Loureiro, R., Caneiro-Queija, B., Benito-González, T., ... Swaans, M. J. (2024). Left Atrial Appendage Occlusion vs Standard of Care after Ischemic Stroke Despite Anticoagulation. JAMA Neurology, 81(11). https://doi.org/10.1001/jamaneurol.2024.2882

@article{95a4923b1eb04eeba3fd871629529598,

title = "Left Atrial Appendage Occlusion vs Standard of Care after Ischemic Stroke Despite Anticoagulation",

abstract = "Importance: Patients with atrial fibrillation (AF) who have ischemic stroke despite taking oral anticoagulation therapy (OAT) have a very high risk of recurrence. Left atrial appendage occlusion (LAAO) is a mechanical stroke prevention strategy that may provide additional protection in patients with thromboembolic events under OAT. Objective: To compare percutaneous LAAO with continuing OAT alone regarding stroke prevention in patients with AF who had a thromboembolic event despite taking OAT. Design, Setting, and Participants: This cohort study was a propensity score-matched comparison of the STR-OAC LAAO cohort, an international collaboration of 21 sites combining patients from multiple prospective registries of patients who underwent LAAO between 2010 and 2022. STR-OAC LAAO cohort patients who had follow-up longer than 3 months were propensity score-matched to a previously published control cohort comprising patients from an established international collaboration of investigator-initiated prospective studies. This control cohort included patients with nonvalvular AF, recent ischemic stroke or transient ischemic attack, and follow-up longer than 3 months who were taking OAT before the index event. Analyses were adjusted for imbalances in gender, age, hypertension, diabetes, and CHA2 DS2-VASc score. Exposure: Left atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group). Main Outcomes and Measures: The primary outcome was time to first ischemic stroke. Results: Four hundred thirty-three patients from the STR-OAC LAAO cohort (mean [SD] age, 72 [9] years; 171 [39\%] females and 262 [61\%] males; mean [SD] CHA2 DS2-VASc score, 5.0 [1.6]) were matched to 433 of 1140 patients (38\%) from the control group. During 2-year follow-up, 50 patients experienced ischemic stroke: an annualized event rate of 2.8\% per patient-year in the STR-OAC LAAO group vs 8.9\% per patient-year in the control group. Left atrial appendage occlusion was associated with a lower risk of ischemic stroke (hazard ratio, 0.33; 95\% CI, 0.19-0.58; P <.001) compared with the control group. After LAAO, OAT was discontinued in 290 patients (67\%), and the remaining 143 patients (33\%) continued OAT after LAAO as an adjunctive therapy. Conclusions and Relevance: In patients with nonvalvular AF and a prior thromboembolic event despite taking OAT, LAAO was associated with a lower risk of ischemic stroke compared with continued OAT alone. Randomized clinical trial data are needed to confirm that LAAO may be a promising treatment option for this population with a very high risk of stroke..",

author = "Moniek Maarse and Seiffge, \{David J.\} and Werring, \{David J.\} and Boersma, \{Lucas V. A.\} and Aarnink, \{Errol W.\} and Nicolai Fierro and Patrizio Mazzone and Alessandro Beneduce and Claudio Tondo and Alessio Gasperetti and Radoslaw Pracon and Marcin Demkow, and Kamil Zieli{\'n}ski and \{de Backer\}, Ole and Kasper Korsholm and Nielsen-Kudsk, \{Jens Erik\} and Rodrigo Est{\'e}vez-Loureiro and Berenice Caneiro-Queija and Tom{\'a}s Benito-Gonz{\'a}lez and \{de Prado\}, \{Armando P. rez\} and Luis Nombela-Franco and Pablo Salinas and David Holmes and Almakadma, \{Abdul H.\} and Sergio Berti and Romeo, \{Maria Rita\} and Alvarez, \{Xavier Millan\} and Dabit Arzamendi and Alla, \{Venkata M.\} and Himanshu Agarwal and Ingo Eitel and Christina Paitazoglou and Xavier Freixa and Pedro Cepas-Guill{\'e}n and Rashaad Chothia and Badejoko, \{Solomon O.\} and Bergmann, \{Martin W.\} and Spoon, \{Daniel B.\} and Maddux, \{James T.\} and Mikhael el-Chami and Pradhum Ram and Luca Branca and Marianna Adamo and Suradi, \{Hussam S.\} and \{van Dijk\}, \{Vincent F.\} and Rensing, \{Benno J. W. M.\} and Annaelle Zietz and Maurizio Paciaroni and Valeria Caso and Masatoshi Koga and Kazunori Toyoda and Bernd Kallm{\"u}nzer and Manuel Cappellari and Duncan Wilson and Stefan Engelter and Swaans, \{Martin J.\}",

year = "2024",

month = nov,

day = "11",

doi = "10.1001/jamaneurol.2024.2882",

language = "English",

volume = "81",

journal = "JAMA Neurology",

issn = "2168-6149",

publisher = "American Medical Association",

number = "11",

}

Maarse, M, Seiffge, DJ, Werring, DJ, Boersma, LVA , Aarnink, EW, Fierro, N, Mazzone, P, Beneduce, A, Tondo, C, Gasperetti, A, Pracon, R, Demkow, M, Zieliński, K, de Backer, O, Korsholm, K, Nielsen-Kudsk, JE, Estévez-Loureiro, R, Caneiro-Queija, B, Benito-González, T, de Prado, APR, Nombela-Franco, L, Salinas, P, Holmes, D, Almakadma, AH, Berti, S, Romeo, MR, Alvarez, XM, Arzamendi, D, Alla, VM, Agarwal, H, Eitel, I, Paitazoglou, C, Freixa, X, Cepas-Guillén, P, Chothia, R, Badejoko, SO, Bergmann, MW, Spoon, DB, Maddux, JT, el-Chami, M, Ram, P, Branca, L, Adamo, M, Suradi, HS, van Dijk, VF, Rensing, BJWM, Zietz, A, Paciaroni, M, Caso, V, Koga, M, Toyoda, K, Kallmünzer, B, Cappellari, M, Wilson, D, Engelter, S & Swaans, MJ 2024, 'Left Atrial Appendage Occlusion vs Standard of Care after Ischemic Stroke Despite Anticoagulation', JAMA Neurology, vol. 81, no. 11. https://doi.org/10.1001/jamaneurol.2024.2882

TY - JOUR

T1 - Left Atrial Appendage Occlusion vs Standard of Care after Ischemic Stroke Despite Anticoagulation

AU - Maarse, Moniek

AU - Seiffge, David J.

AU - Werring, David J.

AU - Boersma, Lucas V. A.

AU - Aarnink, Errol W.

AU - Fierro, Nicolai

AU - Mazzone, Patrizio

AU - Beneduce, Alessandro

AU - Tondo, Claudio

AU - Gasperetti, Alessio

AU - Pracon, Radoslaw

AU - Demkow,, Marcin

AU - Zieliński, Kamil

AU - de Backer, Ole

AU - Korsholm, Kasper

AU - Nielsen-Kudsk, Jens Erik

AU - Estévez-Loureiro, Rodrigo

AU - Caneiro-Queija, Berenice

AU - Benito-González, Tomás

AU - de Prado, Armando P. rez

AU - Nombela-Franco, Luis

AU - Salinas, Pablo

AU - Holmes, David

AU - Almakadma, Abdul H.

AU - Berti, Sergio

AU - Romeo, Maria Rita

AU - Alvarez, Xavier Millan

AU - Arzamendi, Dabit

AU - Alla, Venkata M.

AU - Agarwal, Himanshu

AU - Eitel, Ingo

AU - Paitazoglou, Christina

AU - Freixa, Xavier

AU - Cepas-Guillén, Pedro

AU - Chothia, Rashaad

AU - Badejoko, Solomon O.

AU - Bergmann, Martin W.

AU - Spoon, Daniel B.

AU - Maddux, James T.

AU - el-Chami, Mikhael

AU - Ram, Pradhum

AU - Branca, Luca

AU - Adamo, Marianna

AU - Suradi, Hussam S.

AU - van Dijk, Vincent F.

AU - Rensing, Benno J. W. M.

AU - Zietz, Annaelle

AU - Paciaroni, Maurizio

AU - Caso, Valeria

AU - Koga, Masatoshi

AU - Toyoda, Kazunori

AU - Kallmünzer, Bernd

AU - Cappellari, Manuel

AU - Wilson, Duncan

AU - Engelter, Stefan

AU - Swaans, Martin J.

PY - 2024/11/11

Y1 - 2024/11/11

N2 - Importance: Patients with atrial fibrillation (AF) who have ischemic stroke despite taking oral anticoagulation therapy (OAT) have a very high risk of recurrence. Left atrial appendage occlusion (LAAO) is a mechanical stroke prevention strategy that may provide additional protection in patients with thromboembolic events under OAT. Objective: To compare percutaneous LAAO with continuing OAT alone regarding stroke prevention in patients with AF who had a thromboembolic event despite taking OAT. Design, Setting, and Participants: This cohort study was a propensity score-matched comparison of the STR-OAC LAAO cohort, an international collaboration of 21 sites combining patients from multiple prospective registries of patients who underwent LAAO between 2010 and 2022. STR-OAC LAAO cohort patients who had follow-up longer than 3 months were propensity score-matched to a previously published control cohort comprising patients from an established international collaboration of investigator-initiated prospective studies. This control cohort included patients with nonvalvular AF, recent ischemic stroke or transient ischemic attack, and follow-up longer than 3 months who were taking OAT before the index event. Analyses were adjusted for imbalances in gender, age, hypertension, diabetes, and CHA2 DS2-VASc score. Exposure: Left atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group). Main Outcomes and Measures: The primary outcome was time to first ischemic stroke. Results: Four hundred thirty-three patients from the STR-OAC LAAO cohort (mean [SD] age, 72 [9] years; 171 [39%] females and 262 [61%] males; mean [SD] CHA2 DS2-VASc score, 5.0 [1.6]) were matched to 433 of 1140 patients (38%) from the control group. During 2-year follow-up, 50 patients experienced ischemic stroke: an annualized event rate of 2.8% per patient-year in the STR-OAC LAAO group vs 8.9% per patient-year in the control group. Left atrial appendage occlusion was associated with a lower risk of ischemic stroke (hazard ratio, 0.33; 95% CI, 0.19-0.58; P <.001) compared with the control group. After LAAO, OAT was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued OAT after LAAO as an adjunctive therapy. Conclusions and Relevance: In patients with nonvalvular AF and a prior thromboembolic event despite taking OAT, LAAO was associated with a lower risk of ischemic stroke compared with continued OAT alone. Randomized clinical trial data are needed to confirm that LAAO may be a promising treatment option for this population with a very high risk of stroke..

AB - Importance: Patients with atrial fibrillation (AF) who have ischemic stroke despite taking oral anticoagulation therapy (OAT) have a very high risk of recurrence. Left atrial appendage occlusion (LAAO) is a mechanical stroke prevention strategy that may provide additional protection in patients with thromboembolic events under OAT. Objective: To compare percutaneous LAAO with continuing OAT alone regarding stroke prevention in patients with AF who had a thromboembolic event despite taking OAT. Design, Setting, and Participants: This cohort study was a propensity score-matched comparison of the STR-OAC LAAO cohort, an international collaboration of 21 sites combining patients from multiple prospective registries of patients who underwent LAAO between 2010 and 2022. STR-OAC LAAO cohort patients who had follow-up longer than 3 months were propensity score-matched to a previously published control cohort comprising patients from an established international collaboration of investigator-initiated prospective studies. This control cohort included patients with nonvalvular AF, recent ischemic stroke or transient ischemic attack, and follow-up longer than 3 months who were taking OAT before the index event. Analyses were adjusted for imbalances in gender, age, hypertension, diabetes, and CHA2 DS2-VASc score. Exposure: Left atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group). Main Outcomes and Measures: The primary outcome was time to first ischemic stroke. Results: Four hundred thirty-three patients from the STR-OAC LAAO cohort (mean [SD] age, 72 [9] years; 171 [39%] females and 262 [61%] males; mean [SD] CHA2 DS2-VASc score, 5.0 [1.6]) were matched to 433 of 1140 patients (38%) from the control group. During 2-year follow-up, 50 patients experienced ischemic stroke: an annualized event rate of 2.8% per patient-year in the STR-OAC LAAO group vs 8.9% per patient-year in the control group. Left atrial appendage occlusion was associated with a lower risk of ischemic stroke (hazard ratio, 0.33; 95% CI, 0.19-0.58; P <.001) compared with the control group. After LAAO, OAT was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued OAT after LAAO as an adjunctive therapy. Conclusions and Relevance: In patients with nonvalvular AF and a prior thromboembolic event despite taking OAT, LAAO was associated with a lower risk of ischemic stroke compared with continued OAT alone. Randomized clinical trial data are needed to confirm that LAAO may be a promising treatment option for this population with a very high risk of stroke..

UR - https://www.scopus.com/pages/publications/85209768110

U2 - 10.1001/jamaneurol.2024.2882

DO - 10.1001/jamaneurol.2024.2882

M3 - Article

C2 - 39374446

SN - 2168-6149

VL - 81

JO - JAMA Neurology

JF - JAMA Neurology

IS - 11

ER -

Left Atrial Appendage Occlusion vs Standard of Care after Ischemic Stroke Despite Anticoagulation

Abstract

UN SDGs

Access to Document

Other files and links

Fingerprint

Cite this