Clinical Outcomes of Left Atrial Appendage Occlusion Versus Switch of Direct Oral Anti-coagulant in Atrial Fibrillation

Background Left atrial appendage occlusion (LAAO) has emerged as an alternative to oral anti-coagulation therapy for stroke prevention in atrial fibrillation (AF), but data comparing LAAO with direct oral anti-coagulant (DOAC) is sparse. Method This cohort study compared LAAO (with or without prior anti-coagulation) with a switch of one DOAC to another DOAC. The primary outcome was a composite of all-cause mortality, ischemic stroke and major bleeding. Results A total of 2,350 patients (874 in the LAAO group and 1,476 in the DOAC switch group) were generated by 1:2 propensity score matching. After a mean follow up of 1052 ± 694 days, the primary outcome developed in 215 (24.6%) patients in the LAAO group and in 335 (22.7%) patients in the DOAC switch group (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.80 to 1.12; P=0.516). The LAAO group had a lower all-cause mortality (HR, 0.49; 95% CI, 0.39 to 0.60; P<0.001) and cardiovascular mortality (HR, 0.49; 95% CI, 0.32 to 0.73; P<0.001), but similar risk of ischemic stroke (HR, 0.83; 95% CI, 0.63 to 1.10; P=0.194). The major bleeding risk was similar overall (HR, 1.18; 95% CI, 0.94 to 1.48, P=0.150), but was lower in the LAAO group after 6 months (HR 0.71; 95% CI 0.51 to 0.97; P=0.032). Conclusions LAAO conferred a similar risk of composite outcome of all-cause mortality, ischemic stroke and major bleeding, as compared with DOAC switch. The risks of all-cause mortality and cardiovascular mortality were lower with LAAO. What Is New? What Are the Clinical Implications? ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial This is a cohort retrospective study. ### Funding Statement This study received no funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data could be uploaded for review if requested. * AF : Atrial fibrillation CDARS : Clinical Data and Analysis Reporting System CI : Confidence interval DOAC : Direct oral anti-coagulant(s) eGFR : Estimated glomerular filtration rate HR : Hazard ratio LAAO : Left atrial appendage occlusion