A hybrid strategy of left atrial appendage closure on top of anticoagulation in patients with prior anticoagulation failure: a multicenter study.

Abstract

Introduction: A hybrid strategy involving left atrial appendage closure (LAAC) followed by long‑term anticoagulation may be considered in patients experiencing thromboembolic events or LAA thrombus despite anticoagulant treatment (anticoagulation failure).

Objectives: We aimed to report the adoption rate and outcomes of the hybrid strategy in patients treated with LAAC for thromboembolic indications at 5 centers in Poland.

Patients and methods: High‑volume Polish centers reported outcomes of LAAC after anticoagulation failure between the years 2014 and 2024. The hybrid strategy was compared with other pharmacotherapy regimens (nonhybrid strategy) with respect to thromboembolic events, device‑related thrombus (DRT), and major bleeding occurrence.

Results: Out of 1625 patients undergoing LAAC procedures across 5 centers, 141 (8.7%) had a history of anticoagulation failure. The hybrid strategy was applied in 64 individuals (45%), and its rate increased from 0% in 2014 to 80% in 2024. As compared with the nonhybrid group, the patients treated with the hybrid strategy more often received newer‑generation occluders (98.4% vs 68.8%; P <0.001), had lower rates of prior bleeding (12.5% vs 35.1%; P = 0.003) and lower HAS‑BLED scores (median [interquartile range], 3 [2-3] vs 3 [2-4] points; P = 0.008), and more often had a history of LAA thrombus (23.4% vs 10.4%; P = 0.04) and left ventricular ejection fraction below 40% (18.8% vs 6.5%; P = 0.04). During a median 1.3‑year follow‑up, the hybrid strategy showed greater thromboembolic risk reduction relative to the CHA2DS2‑VASc-predicted rate (91% vs 60%; annualized event rates of 1.1% vs 5.5%), and greater major bleeding risk reduction relative to the HAS‑BLED-predicted rate (100% vs 73%; annualized rates of 0% vs 1.7%), with similar DRT rates (6.9% vs 6.8%; P >0.99).

Conclusions: In patients with anticoagulant treatment failure, the hybrid strategy (LAAC + long‑term anticoagulation) is increasingly adopted and was associated with greater thromboembolic risk reduction, as compared with the standard nonhybrid strategy, without compromising the bleeding profile.