Outcome After Simultaneous PCI and Left Atrial Appendage Occlusion

Aims: To investigate feasibility and safety of concomitant percutaneous coronary intervention (PCI) and left atrial appendage occlusion (LAAO) as compared to PCI in combination with antithrombotic treatment in patients with coronary artery disease and nonvalvular atrial fibrillation (AF). Methods and results: Patients with AF undergoing concomitant PCI with drug-eluting stents (DES) and LAAO with dedicated devices were consecutively entered into a prospective single-centre registry and were compared to AF patients from the Bern DES registry treated with different antithrombotic strategies. Among 379 patients with AF, 56 patients were treated with concomitant PCI and LAAO, 268 patients were treated with PCI and dual therapy (DT), and 55 patients were started on triple antithrombotic therapy (TT). Clinical follow-up was assessed by standardised telephone interviews. Patients with PCI + LAAO were older (76 ± 7 years) as compared to patients with PCI + DT (72 ± 9 years) or PCI + TT (73 ± 8 years) (p <0.01). They more commonly had a history of cerebrovascular events (31% vs 10% vs 16%, p <0.001). CHA₂DS₂-vasc scores amounted to 3.5 ± 2.2, 3.6 ± 1.3, and 4.2 ± 1.3 among patients with PCI + LAAO, PCI + DT, and PCI + TT, respectively (p = 0.03). At 30 days, the composite of all-cause death, myocardial infarction, ischemic stroke, or BARC bleeding type 3–5 was documented in 12.5% of patients undergoing PCI + LAAO, 8.2% in patients with PCI + DT, and 9.2% in patients with PCI + TT, with no significant differences between groups in an age-adjusted analysis (PCI + DT being the reference; PCI + LAAO: HR 1.27 (95% CI 0.54–2.99), p = 0.58; PCI + TT (1.19 [95% CI 0.49–2.92], p = 0.70). Two patients (3.6%) with PCI + LAAO suffered a periprocedural stroke, and 5 patients (8.9%) were recorded to have bleeding BARC type 3a or 3b. At 1 year, all-cause mortality in patients with PCI + DT, amounted to, 6.7% (reference). It was 6.3% (HR 0.51, 95%CI 0.12– 2.20, p = 0.36) and 18.2% (HR 2.89, 95% CI 1.33–6.26, p <0.01) in PCI + LAAO and PCI + TT, respectively. There was no difference with regards to the composite of all-cause death, myocardial infarction, ischaemic stroke, or bleeding (BARC type 3–5) (PCI + DT being the reference; PCI + LAAO: HR 1.17 (95% CI 0.56–2.45), p = 0.67; PCI + TT (1.68 [95% CI 0.89–3.15], p = 0.11). Conclusion: PCI with concomitant LAAO is a feasible alternative to combined anti-platelet and anti-thrombotic management in patients with CAD and AF. Longer-term follow-up will be needed to demonstrate efficacy.