Closure of the atrial appendage was superior to oral anticoagulation in safety and noninferior in effectiveness.

Multiple trials have shown that left atrial appendage occlusion has efficacy similar to oral coagulation (typically warfarin) in patients at elevated stroke risk. Whether this approach is effective in patients undergoing ablation of atrial fibrillation (AF) was tested in an industry-­sponsored trial (NCT03795298).

The 1600 patients (mean age, 70 years; mean CHA₂Ds₂­-VASc score, 3.5; nonwarfarin anticoagulant, 95%) received AF ablation and were randomised to oral anticoagulation or left atrial appendage occlusion with a device (Watchman). Device recipients continued anticoagulation for three months and aspirin for a year.

At three-­year follow up, results were as follows:

• rates of major or clinically relevant nonprocedural bleeding (the primary safety endpoint) were 8.5% with the device and 18.1% with anticoagulation, showing superiority for the device
• rates of death, stroke or systemic embolism (the primary efficacy end­ point) were 5.3% with the device and 5.8% with anticoagulation (absolute risk difference −0.5%, 97.5% upper confidence limit +1.8%, which was less than the prespecified noninferi­ority threshold of +5.0%).

Comment: Patients with high CHA₂Ds₂­-VASc scores who are undergoing AF ablation might benefit from concomitant left atrial appendage closure. Whether this finding applies to all patients or selected patients is not clear. We need to see more data. Confirmation of these findings could be practice changing.

Mark S. Link, MD, Professor of Medicine and Director, Cardiac Electrophysiology, UT Southwestern Medical Center, Dallas, USA.

Wazni OM, et al. Left atrial appendage closure after ablation for atrial fibrillation. N Engl J Med 2024 Nov 16; e-pub (https:// doi.org/10.1056/NEJMoa2408308).

This summary is taken from the following Journal Watch titles: Cardiology, Hospital Medicine, General Medicine, Ambulatory Medicine, Neurology.