Chatani Ryuki, Kubo Shunsuke, Tasaka Hiroshi, Nishiura Naoki, Mushiake Kazunori, Ono Sachiyo, Maruo Takeshi, Kadota Kazushige
Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.
Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.
Heart Rhythm. 2025 Feb;22(2):475-485. doi: 10.1016/j.hrthm.2024.10.061. Epub 2024 Nov 8.
Patients with atrial fibrillation and malignant left atrial appendage (LAA) may benefit from LAA closure (LAAC); however, evidence is limited.
The purpose of this study was to determine management strategies and clinical outcomes in patients with atrial fibrillation and malignant LAA.
Malignant LAA was defined as a history of ischemic stroke and/or evidence of LAA thrombus despite continuous oral anticoagulation (OAC) therapy (continuous for ≥3 weeks). We studied 80 patients with malignant LAA treated with LAAC. We compared these patients first against 44 patients with malignant LAA treated with OAC alone and second against 114 patients without malignant LAA who were treated with LAAC for conventional indications.
Among patients with malignant LAA (first comparison), those treated with LAAC had a higher 1-year cumulative incidence rate of ischemic stroke than did patients treated with OAC alone (6.3% vs 5.3%; log-rank, P = .09) whereas the difference in stroke risk while receiving OAC was comparable (2.7% vs 5.3%; log-rank, P = .84). Furthermore, all disabling stroke events in patients with malignant LAA treated with LAAC occurred only while not receiving OAC. Among patients treated with LAAC (second comparison), those with malignant LAA had a higher 1-year cumulative incidence rate of ischemic stroke (and ischemic stroke due to device-related thrombosis) than did those without malignant LAA (6.3% vs 2.2%; log-rank, P = .009 and 2.2% vs 0%; log-rank, P = .04, respectively). However, these differences in stroke risk were no longer significant while receiving OAC (2.7% vs 1.0%; log-rank, P = .11).
Combination performing LAAC and continuation of OAC may be options to prevent ischemic stroke in patients with high thromboembolic risk and malignant LAA.
心房颤动合并恶性左心耳（LAA）的患者可能从左心耳封堵术（LAAC）中获益；然而，证据有限。
本研究旨在确定心房颤动合并恶性LAA患者的管理策略和临床结局。
恶性LAA定义为尽管持续口服抗凝（OAC）治疗（持续≥3周）仍有缺血性卒中病史和/或LAA血栓证据。我们研究了80例接受LAAC治疗的恶性LAA患者。我们首先将这些患者与44例仅接受OAC治疗的恶性LAA患者进行比较，其次与114例因传统适应证接受LAAC治疗的无恶性LAA患者进行比较。
在恶性LAA患者中（首次比较），接受LAAC治疗的患者1年缺血性卒中累积发生率高于仅接受OAC治疗的患者（6.3%对5.3%；对数秩检验，P = 0.09），而接受OAC时的卒中风险差异相当（2.7%对5.3%；对数秩检验，P = 0.84）。此外，接受LAAC治疗的恶性LAA患者中所有致残性卒中事件仅在未接受OAC时发生。在接受LAAC治疗的患者中（第二次比较），有恶性LAA的患者1年缺血性卒中（以及与器械相关血栓形成导致的缺血性卒中）累积发生率高于无恶性LAA的患者（6.3%对2.2%；对数秩检验，P = 0.009和2.2%对0%；对数秩检验，P = 0.04）。然而，接受OAC时这些卒中风险差异不再显著（2.7%对1.0%；对数秩检验，P = 0.11）。
LAAC联合OAC持续治疗可能是预防高血栓栓塞风险和恶性LAA患者缺血性卒中的选择。
