房颤合并晚期慢性肾脏病患者左心耳封堵与抗凝治疗的比较

: Chronic kidney disease (CKD) is a significant risk factor for thrombogenic and bleeding events in patients with atrial fibrillation (AF). Left atrial appendage occlusion (LAAO) is increasingly utilized as an alternative to oral anticoagulation. We aimed to compare LAAO against medical therapy in advanced CKD patients (A-CKD). : We conducted a retrospective cohort study to compare patients with AF who had undergone LAAO (intervention group) or patients receiving oral anticoagulation (OAC) (control group). All of them had the diagnosis of A-CKD (estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m). The primary endpoint was a composite of stroke, transient ischemic attack (TIA), systemic embolism (SE), and major bleeding. Secondary endpoints included: an efficacy combined endpoint (a composition of stroke, TIA, and SE); major bleedings (defined as Bleeding Academic Research Consortium (BARC) ≥ 3), and mortality at follow-up. A propensity score matching was used to balance the populations. : In total, 81 and 102 patients composed the LAAO and anticoagulation groups. Mean age was 78.27 ± 10.3 and 81.2 ± 9.07 ( = 0.069) and female sex was 38.3% and 44.1%, respectively. Patients who underwent LAAO had a higher HAS-BLED score: 3.46 ± 0.85 vs. 3.77 ± 1.06, = 0.011. Median follow-up was 19.0 months [IQR: 10.9-33.5]. There were no differences in the primary combined endpoint at 3-years follow-up-22.2% vs. 34.2% (hazard ratio (HR) 0.63, CI-95%: 0.353-1.11, = 0.102)-nor respecting the efficacy combined endpoint: 3.7% vs. 6.9% (HR 0.54, CI-95%: 0.14-2.09, = 0.355). Patients under anticoagulation treatment did present major bleedings (BARC ≥ 3) more often than the intervention group: 38.3%vs50% (HR 0.52, CI-95%: 0.28-0.96, = 0.031). A total of 15 patients (14.7%) from the control group underwent LAAO during follow-up. After a propensity score matching analysis, the primary combined endpoint was more frequent in the control group (HR 0.47, CI-95%: 0.25-0.90, = 0.019). : Compared with oral anticoagulation therapy, LAAO had no differences in efficacy, but fewer major bleeding rates were found.

慢性肾脏病（CKD）是心房颤动（AF）患者发生血栓形成和出血事件的重要危险因素。左心耳封堵术（LAAO）越来越多地被用作口服抗凝治疗的替代方法。我们旨在比较晚期CKD患者（A-CKD）接受LAAO与药物治疗的效果。

我们进行了一项回顾性队列研究，比较接受LAAO的AF患者（干预组）和接受口服抗凝治疗（OAC）的患者（对照组）。所有患者均诊断为A-CKD（估计肾小球滤过率（eGFR）<30 mL/min/1.73 m²）。主要终点是卒中、短暂性脑缺血发作（TIA）、全身性栓塞（SE）和大出血的复合终点。次要终点包括：疗效联合终点（卒中、TIA和SE的组合）；大出血（定义为出血学术研究联盟（BARC）≥3级），以及随访期间的死亡率。采用倾向评分匹配法平衡两组人群。

LAAO组和抗凝治疗组分别有81例和102例患者。平均年龄分别为78.27±10.3岁和81.2±9.07岁（P = 0.069），女性分别占38.3%和44.1%。接受LAAO的患者HAS-BLED评分更高：3.46±0.85 vs. 3.77±1.06，P = 0.011。中位随访时间为19.0个月[四分位间距：10.9 - 33.5个月]。3年随访时，主要联合终点无差异——分别为22.2%和34.2%（风险比（HR）0.63，95%置信区间：0.353 - 1.11，P = 0.102），疗效联合终点也无差异：分别为3.7%和6.9%（HR 0.54，95%置信区间：0.14 - 2.09，P = 0.355）。接受抗凝治疗的患者大出血（BARC≥3级）的发生率高于干预组：38.3% vs 50%（HR 0.52，95%置信区间：0.28 - 0.96，P = 0.031）。对照组共有15例患者（14.7%）在随访期间接受了LAAO。经过倾向评分匹配分析，对照组的主要联合终点更常见（HR 0.47，95%置信区间：0.25 - 0.90，P = 0.019）。

与口服抗凝治疗相比，LAAO在疗效上无差异，但大出血发生率更低。