Post-cardioversion anticoagulation in atrial fibrillation with left atrial appendage occlusion: Necessary or not?

The role of post-cardioversion oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and left atrial appendage occlusion (LAAO) remains unclear. Limited evidence exists regarding stroke, systemic thromboembolism (SSTEs), and bleeding risks in this population.

To evaluate the clinical outcomes following electrical cardioversion (eCVN) in patients with AF and prior LAAO.

We conducted a retrospective cohort study using the TriNetX Research Network to identify patients with prior surgical or percutaneous LAAO, no history of stroke, and no OAC use for at least 1 month prior to eCVN for AF between January 1, 2014, and November 1, 2024. Propensity score matching (PSM) was used to compare outcomes between those who received ≥1 month of OAC post-cardioversion (AC group) and those who did not (Non-AC group). Primary outcomes were SSTEs and significant bleeding.

Among 1507 eligible patients, 583 (38.7 %) received post-cardioversion OAC. After PSM, 551 patients per group were analyzed. The AC group had a numerically lower but not statistically significant rate of SSTEs (OR 0.59, 95 % CI: 0.31-1.13) and ischemic stroke/transient ischemic attack (OR 0.69, 95 % CI: 0.35-1.92). Significant bleeding was similar between groups (6.0 % vs. 5.3 %; OR 1.15, 95 % CI: 0.67-1.92).

Among patients with AF and prior surgical and percutaneous LAAO undergoing cardioversion, post-procedure OAC use was not associated with significant differences in SSTEs or bleeding risk. Prospective studies are warranted to inform clinical guidelines.