Left atrial appendage closure in patients with cardioembolic stroke despite oral anticoagulant therapy: a multicenter case-control study

Abstract Introduction cardioembolic stroke in patients with non-valvular atrial fibrillation (nvAF) despite adequate oral anticoagulation (OAC) is rare but at high risk of recurrence and death. Left atrial appendage closure (LAAC) is even more used in patients with OAC failure, despite comparative studies with the current standard of care are lacking. Purpose this is a multicenter, retrospective, case-control study aimed to compare the effectiveness of the hybrid strategy LAAC + OAC versus the current standard of care in patients with cardioembolic stroke despite adequate OAC. Methods consecutive patients were retrospectively enrolled from three Italian centers between May 2012 and November 2023. Patients were divided according to the treatment strategy following the index event in LAAC group and Medical Therapy (MT) group. The primary endpoint was a composite of all cause death, cardioembolic events (CEs), and major bleeding, while secondary endpoints were CE events. Results among the 109 patients included in the study (mean age 76 ± 8 years, 52 females), 42 formed the LAAC group and 67 the MT group. The major part (79.8%) was on direct oral anticoagulant at the index event. Median CHA2DS2-VA was 5 ± 2 and median NIH Stroke scale was 9 (range 3:31). 1:1 propensity score matching was performed. At a median follow up of 39 ± 14 months, the LAAC group reported lower rate of primary endpoint (HR 0.25, 95 %CI 0.11-0.66, p = 0.003) and lower rate of secondary endpoint (HR 0.25, 95 %CI 0.09–0.92, p = 0.046). No significant differences were detected regarding the type of DOAC assumed. Conclusion the hybrid strategy LAAC + OAC was associated with higher free from primary and secondary endpoint with respect to standard of care in nvAF patients with cardioembolic stroke despite adequate OAC.