Antithrombotic Therapy and Device-Related Thrombosis Following Endovascular Left Atrial Appendage Closure

JACC Cardiovasc Interv. 2019 Jun 10;12(11):1067-1076. doi: 10.1016/j.jcin.2018.11.001. Epub 2019 May 15.

Abstract

Objectives: The aim of this study is to review the evidence on the use of antithrombotic therapy and risk of device-related thrombosis after left atrial appendage closure.

Background: Left atrial appendage closure (LAAC) is increasingly performed for stroke prevention in patients with nonvalvular atrial fibrillation, especially those who cannot tolerate or are ineligible for oral anticoagulation.

Methods: After device implantation for LAAC, different antithrombotic regimens with varying duration of therapy are currently used. Such selection depends on patients' risk for bleeding and physicians' choice.

Results: Device-related thrombosis remains an Achilles' heel of LAAC, and the etiology remains incompletely understood. Dual-antiplatelet therapy, and direct oral anticoagulation may have similar safety and device-related thrombosis occurrence in real-world LAAC registries compared with warfarin and aspirin. Device imaging surveillance should be routinely performed to assess for device-related thrombosis, which if diagnosed should be treated aggressively, as it is associated with higher thromboembolic risks.

Conclusions: Given the uncertainties and therapeutic dilemma, the authors provide an in-depth discussion of the options and rationale for antithrombotic therapy post-LAAC.

Keywords: atrial fibrillation; device-related thrombus; left atrial appendage closure.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Animals
  • Atrial Appendage* / diagnostic imaging
  • Atrial Appendage* / physiopathology
  • Atrial Fibrillation / diagnosis
  • Atrial Fibrillation / physiopathology
  • Atrial Fibrillation / therapy*
  • Atrial Function, Left
  • Endovascular Procedures / adverse effects
  • Endovascular Procedures / instrumentation*
  • Fibrinolytic Agents / administration & dosage*
  • Fibrinolytic Agents / adverse effects
  • Humans
  • Prosthesis Design
  • Risk Assessment
  • Risk Factors
  • Thrombosis / diagnosis
  • Thrombosis / etiology
  • Thrombosis / prevention & control*
  • Time Factors
  • Treatment Outcome

Substances

  • Fibrinolytic Agents