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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Incidence and Predictors of Clinically Significant Bleedings after Transcatheter Left Atrial Appendage Closure
Kamil Zieliński1, Radosław Pracoń1, Marek Konka2
1Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland.
Insights
Clinically significant bleeding (CSB) after transcatheter left atrial appendage closure (LAAC) occurred in 7.2% of patients, often recurring from prior bleeding sites. High blood pressure, history of epistaxis, permanent atrial fibrillation, and prior GI bleeding predicted post-LAAC CSB.
Area of Science:
- Cardiology
- Interventional Cardiology
- Hemorrhagic Risk Management
Background:
- Transcatheter left atrial appendage closure (LAAC) is an alternative for patients with high bleeding risk on anticoagulation.
- Understanding post-procedural bleeding is crucial for optimizing patient management.
Purpose of the Study:
- To determine the incidence and predictors of clinically significant bleeding (CSB) following LAAC.
- To identify risk factors for nonprocedural CSB after LAAC.
Main Methods:
- Analysis of 195 patients undergoing LAAC with Amplatzer or WATCHMAN devices (May 2014 - Nov 2019).
- CSB defined by specific criteria including death, hemoglobin drop, transfusion, critical site, or hospitalization.
- Multivariable analysis to identify predictors of post-LAAC CSB.
Main Results:
- 14 patients (7.2%) experienced 15 nonprocedural CSBs, predominantly during dual antiplatelet therapy (DAPT).
- CSBs often recurred at the same site as previous bleeding events.
- Predictors of CSB included admission systolic blood pressure > 127 mmHg, history of epistaxis, permanent atrial fibrillation, and prior gastrointestinal bleeding.
Conclusions:
- Nonprocedural CSBs post-LAAC are associated with prior bleeding sites and occur more frequently during DAPT.
- Elevated admission systolic blood pressure, epistaxis history, permanent AF, and GI bleeding history are significant predictors.
- Further research is needed on tailored antiplatelet strategies and blood pressure control to mitigate bleeding risk.
Background:
Transcatheter left atrial appendage closure (LAAC) is performed in patients unsuitable for long-term anticoagulation, predominantly due to prior bleeding events. The study aimed to investigate the incidence and predictors of clinically significant bleeding (CSB) post-LAAC.
Methods:
Consecutive patients after LAAC with an Amplatzer or WATCHMAN device were analyzed (05.2014-11.2019). Bleeding was classified as CSB when associated with at least one of the following: death, ≥2 g/dL hemoglobin drop, ≥2 blood units transfusion, critical anatomic site, or hospitalization/invasive procedure.
Results:
Among 195 patients (age 74 (68-80), 43.1% females, HAS-BLED score 2.0 (2.0-3.0)), during median follow-up of 370 (IQR, 358-392) days, there were 15 nonprocedural CSBs in 14 (7.2%) patients. Of those, 9 (60.0%) occurred during postprocedural dual antiplatelet therapy (DAPT) (median 46 (IQR: 16-60) days post-LAAC) vs. 6 (40%) after DAPT discontinuation (median 124 (81-210) days post-LAAC), translating into annualized CSB rates of 14.0% (per patient-year on DAPT) vs. 4.6% (per patient-year without DAPT). In 92.9% (13/14) of patients, the post-LAAC nonprocedural CSB was a recurrence from the same site as bleeding pre-LAAC. In the multivariable model, admission systolic blood pressure (SBP) > 127 mmHg (HR = 10.73, 1.37-84.26, p = 0.024), epistaxis history (HR = 5.84, 1.32-25.89, p = 0.020), permanent atrial fibrillation (AF) (HR = 4.55, 1.20-17.20, p = 0.025), and prior gastrointestinal bleeding (HR = 3.35, 1.01-11.08, p = 0.048) predicted post-LAAC CSB.
Conclusions:
Nonprocedural CSBs after LAAC, with a similar origin as the pre-LAAC bleedings, were observed predominantly during postprocedural DAPT and predicted by elevated admission SBP, prior epistaxis, permanent AF, and gastrointestinal bleeding history. Whether a more reserved post-LAAC antiplatelet regimen and stringent blood pressure control may improve LAAC outcomes remains to be studied.
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