Effect of Glomerular Filtration Rates on Outcomes Following Percutaneous Left Atrial Appendage Closure

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Scarce data support the prescription of oral anticoagulation in patients with concomitant advanced chronic kidney disease (CKD) and atrial fibrillation, and left atrial appendage closure (LAAC) may provide a favorable risk-benefit ratio in this population. However, outcomes of LAAC in CKD patients are unknown. We aimed to investigate the impact of moderate-to-severe CKD on clinical outcomes following percutaneous LAAC. This was a multicenter study including 1094 patients who underwent LAAC. Moderate-to-severe CKD was defined as an eGFR<45 mL/min. Death, ischemic stroke, severe bleeding (≥BARC 3a) and serious adverse event (SAE; composite of death, stroke or severe bleeding) were recorded. A total of 300 patients (27.4%) had moderate-to-severe CKD. There were no differences between groups in periprocedural complications or device related thrombosis. At a median follow-up of 2 (1 to 3) years, patients with moderate-to-severe CKD did not present an increased risk of ischemic stroke (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.22 to 1.92; p = 0.435) but were at a higher risk of death (HR: 2.84; 95% CI: 2.22 to 3.64; p <0.001), severe bleeding (HR: 1.96; 95% CI: 1.36 to 2.81; p <0.001) and SAE (HR: 2.23; 95% CI: 1.80 to 2.77; p <0.001). By multivariable analysis, an eGFR<45 ml/min (HR: 1.92; 95% CI: 1.34 to 2.76; p <0.001) and previous bleeding (HR: 2.30; 95% CI: 1.27 to 4.17; p = 0.006) were associated with an increased risk of severe bleeding. In conclusion, patients with moderate-to-severe CKD who underwent LAAC had very high thrombotic and bleeding risks. Although the rates of device related thrombosis or ischemic stroke after-LAAC were not influenced by kidney dysfunction, patients with moderate-to-severe CKD remained at higher risk of severe bleeding events.

Section snippets

Methods

This was a multicenter study including 1094 patients who underwent percutaneous LAAC in 8 centers. LAAC was performed as previously reported,8 and the approach and device used were left at the discretion of the operators. Patients with failure to implant a device in the left atrial appendage were not included in the present analysis. Most procedures were performed under general anesthesia and trans-esophageal echocardiography (TEE) guidance. After-LAAC management consisted of short term (1 to 3

Results

The main baseline characteristics of the study population are shown in Table 1. The mean patient's age was 75.9±8.4 years, with 38.8% of women. Mean CHA2DS2-VASc and HAS-BLED scores were 4.5±1.5 and 3.6±1.1, respectively. A total of 324 patients (29.6%) had a prior ischemic stroke. Most patients (80.9%) experienced a previous bleeding, of whom 380 (34.7%) had multiple bleeding episodes. A total of 300 patients (27.4%) had an eGFR<45ml/min, including 47 patients with hemodialysis. Patients with

Discussion

Some studies have reported an increased risk of stroke in AF patients with CKD.5,6 Despite the high thrombotic risk observed in CKD patients,11 specific data regarding the efficacy of LAAC in this population were lacking. The present study failed to identify any increase in the thrombotic risk (DRT, ischemic stroke, TIA or peripheral embolism) associated with CKD, and provided reassuring information regarding the efficacy of LAAC in such patients. In fact, the rate of ischemic stroke observed

Disclosures

Dr Laurent Faroux received fellowship support from Institut Servier and the Association Régionale de Cardiologie de Champagne-Ardenne (ARCCA), and research grant from Biotronik, Edwards Lifesciences and Medtronic. Dr. Rodés-Cabau has received institutional research grants from Boston Scientific. Dr. Cruz-Gonzalez is proctor for Abbott, Boston and Lifetech. Dr. Freixa is proctor for Abbott and Lifetech. Dr. Nombela-Franco is proctor for Abbott. Dr. Arzamendi is proctor for Abbott and Boston

Credit Author Statement

Laurent Faroux: Methodology, Formal Analysis, Investigation, Writing – Original Draft; Ignacio Cruz-González: Investigation, Writing – Review & Editing; Dabit Arzamendi: Investigation, Writing – Review & Editing; Xavier Freixa: Investigation, Writing – Review & Editing; Luis Nombela-Franco: Investigation, Writing – Review & Editing; Vicente Peral: Investigation, Writing – Review & Editing; Berenice Caneiro-Queija: Investigation, Writing – Review & Editing; Antonio Mangieri: Investigation,

Declaration of Interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this study.

Acknownledgment

Dr. Rodés-Cabau holds the Research Chair “Fondation Famille Jacques Larivière” for the Development of Structural Heart Disease Interventions. Dr. Cruz-González received research grants from the Instituto de Salud Carlos III (PI19/00658) and from the Gerencia Regional de Salud de la Junta de Castilla y León (GRS 3031/A/19).

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