Which Anticoagulants Should Be Used for Stroke Prevention in Non-Valvular Atrial Fibrillation and Severe Chronic Kidney Disease?

Philip A. Kalra; Alexandru Burlacu; Charles J. Ferro; Adrian Covic

Disclosures

Curr Opin Nephrol Hypertens. 2018;27(6):420-425. 

In This Article

Avoiding the Need for Oral Anticoagulation in Chronic Kidney Disease Patients With Atrial Fibrillation: Left Atrial Appendage Occlusion Devices

Left atrial appendage (LAA) occlusion was originally proposed as a solution in cases where oral anticoagulation was contraindicated. Recent European guidelines have emphasized its potential value in the management of atrial fibrillation in certain complex patients.[25] The initial recommendation cited serious complications and high event rates but optimization of the implantation technique, the design of different LAA occluder devices, and the inclusion of a large number of patients in RCTs comparing their effects with warfarin has shown a reduced rate of peri-procedural complications and favourable long-term outcomes.[26] The use of these devices is attractive from two perspectives – reducing the risk of thromboembolism by excluding the LAA (as a potential source of thrombus) and also lowering the risk of bleeding by not using OAC. A consensus document has recently standardized the indications for LAA occlusion, patient selection, staff skills, organization and training.[27] One of the categories included in the list of indications is patients with severe CKD or undergoing dialysis.

Three recent LAA occlusion studies are of interest. The first one included 28 patients with atrial fibrillation and LAA thrombus. Technical and procedural success was achieved in all patients and no death or thromboembolic events were reported.[28] Procedural success was attributed to team experience. Du et al. have combined two procedures, LAA occlusion followed by atrial ablation, in the same intervention in nonvalvular atrial fibrillation patients and found favourable safety and efficacy.[29] A study has now investigated the feasibility and efficacy of LAA occlusion in 50 dialysis patients; the preliminary results showed that all devices were implanted successfully and no deaths or major adverse events were reported during the ensuing 30 days.[30] It should be noted that use of these devices may also require long-term dual antiplatelet therapy which itself incurs a risk of bleeding.

Although LAA occlusion procedures are in their infancy these early results suggest that they are safe and effective; they may eventually provide a viable solution for those CKD 5/5D patients with a high risk of bleeding and thrombosis, although the need for an experienced 'high volume' centre with skilled interventional team should be emphasized.

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