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Left Atrial Appendage Closure Device versus Oral Anticoagulation for the Treatment of Non-Valvular Atrial Fibrillation

August 2020

Abstract

Background: Atrial fibrillation (AF) is a common medical condition in the U.S. affecting over 2.3 million people. AF is a disease that is often cardiogenic in nature, but the complications that arise from AF can be multisystemic in particular due to blood clot formation within the left atrial appendage (LAA). The focus of this study is to assess and compare left atrial appendage closure (LAAC) devices versus traditional oral anticoagulation (OAC) in the prevention of subsequent complications that may arise from nonvalvular AF (NVAF).

Methods: An exhaustive search of available medical literature using the search engines Pubmed NCBI, Google Scholar, and CINAHL was conducted with the following search terms: non-valvular atrial fibrillation, Watchman or left atrial appendage occlusion device, anticoagulation or warfarin, stroke, and bleeding. Articles that resulted from the search were screened for relevance and eligibility criteria prior to being included in the systematic review.

Results: The exhaustive search across all 3 search engines resulted in 71 articles that were evaluated for relevance, eligibility and quality. After evaluation, 5 articles qualified to be included in this critically appraised topic including 2 randomized controlled trials (RCT), 1 network meta-analysis (NMA), and 2 observational studies. Across all studies, LAAC devices showed increased complication risk in the peri-procedural time period but decreased risk of all cause mortality. The LAAC device also showed better cost effectiveness when compared with warfarin and novel oral anticoagulants (NOACs).

Conclusion: The LAAC device did not achieve non-inferiority to OAC in the prevention of ischemic stroke and also had increased risk of major bleeding in the peri-procedural time frame (specifically the 7 days following placement of the device). However, LAAC devices did show decreased all cause mortality risk (secondary efficacy endpoint) and increased cost effectiveness long term when compared with OAC. NOACs appeared to perform best in primary efficacy (prevention of stroke and systemic embolism) and primary safety (major bleedings), though they were the least cost effective treatment modality studied.

Keywords: Non-valvular atrial fibrillation, Watchman or left atrial appendage occlusion device, anticoagulation or warfarin, stroke, bleeding, and cost effectiveness.

Files

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Wicks_K_Final.pdf
20 May 2020
Public
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