From the Guidelines
True. Ongoing randomized controlled trials (RCTs) comparing endovascular left atrial appendage closure to direct oral anticoagulants (DOACs) will provide definitive answers about survival benefits and optimal postprocedural antithrombotic therapy, as stated in the 2024 ESC guidelines for the management of atrial fibrillation 1. These trials are essential because current evidence has limitations in directly comparing these approaches.
Key Points
- The PRAGUE-17 trial showed non-inferiority of LAAO (Watchman or Amulet) to DOAC for a broad composite primary endpoint of stroke, TIA, systemic embolism, cardiovascular death, major or non-major clinically relevant bleeding, procedure/device-related complications 1.
- Larger trials are expected to provide more comprehensive data that can add to the current evidence base, which will help determine whether left atrial appendage closure offers mortality benefits compared to DOACs and will establish evidence-based protocols for antithrombotic management after closure procedures.
- The results will guide clinicians in selecting the most appropriate stroke prevention strategy for patients with atrial fibrillation, particularly those at high bleeding risk or with contraindications to long-term anticoagulation.
Current Evidence
The current evidence base includes studies such as the PRAGUE-17 trial, which compared LAAO to DOAC and found non-inferiority for a broad composite primary endpoint 1. Additionally, the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack recommends the use of DOACs over VKAs due to their improved safety profile 1.
Future Directions
Ongoing RCTs will provide definitive answers about the survival benefits and optimal postprocedural antithrombotic therapy of endovascular left atrial appendage closure compared to DOACs, which will help guide clinicians in selecting the most appropriate stroke prevention strategy for patients with atrial fibrillation.
From the Research
Answer to the Question
The answer to the question is: True
Rationale
- Ongoing RCTs comparing endovascular left atrial appendage closure to DOACs will provide definitive answers on survival benefits and postprocedural antithrombotic therapy 2, 3, 4.
- Current studies have evaluated the efficacy and safety of reduced doses of rivaroxaban after left atrial appendage closure, suggesting that it may be a viable alternative to dual antiplatelet therapy 2, 5.
- The optimal antithrombotic therapy after left atrial appendage closure remains unclear, with various regimens being used in observational studies 3, 4.
- Future studies will investigate the role of direct anticoagulants for post-implant thrombus formation and address the question of whether left atrial appendage closure obviates the need for long-term aspirin therapy 3, 4.
Key Findings
- Reduced doses of rivaroxaban have been shown to be effective in reducing thrombin generation and device-related thrombosis after left atrial appendage closure 2, 5.
- Dual antiplatelet therapy is commonly used after left atrial appendage closure, but the optimal duration of antithrombotic therapy remains unclear 3, 6.
- Left atrial appendage closure may be a feasible option for patients at very high bleeding risk, with some studies suggesting that discontinuation of antithrombotic therapy after the procedure may be safe and feasible 6.