Direct Oral Anticoagulant Versus Warfarin After Left Atrial Appendage Closure With WATCHMAN: Updated Systematic Review and Meta-analysis |
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| Institution: | 1. Department of Internal Medicine, Rochester General Hospital, Rochester, NY;2. Department of Cardiology, Mayo Clinic Arizona, Phoenix, AZ;3. Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN;4. Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY;5. Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY;1. Internal Medicine, University of Texas Medical Branch, Galveston, TX;2. Cardiology, University of Texas Medical Branch, Galveston, TX;1. Department of Medicine, University of Mississippi Medical Center, Jackson, MS;2. Department of Medicine, Forrest General Hospital, Hattiesburg, MS;3. Division of Cardiology, Duke University School of Medicine, Durham, NC;4. Duke Clinical Research Institute, Durham, NC;5. Department of Medicine, McMaster University, Hamilton, Ontario, Canada;6. Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada;7. Research Institute of St. Joe''s and Population Health Research Institute, Hamilton, Ontario, Canada;8. Division of Cardiology, Department of Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, CA;9. Baylor Scott and White Research Institute, Dallas, Texas;1. Phytochemistry Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran;2. Department of Pharmacognosy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, ,Tehran, Iran;3. Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran;4. Department of Genetics? Shahid Sadoughi University of Medical Sciences, Yazd, Iran;5. Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran;6. Epidemiology and Biostatistics Department, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran;7. Applied Physiology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran;8. Central Research Laboratories, Shahid Beheshti University of Medical Sciences, Tehran, Iran;9. Department of Medicinal Chemistry, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran;10. Department of Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Karachi, Pakistan;11. Department of Pharmaceutical Chemistry, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Karachi, Pakistan;1. Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Spain;2. Anesthesiology Department, Hospital Clinic, Spain;3. Institut d''Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain;4. Centro de Investigación Biomédica en Red (CIBERCV), Instituto de Salud Carlos III, Spain |
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| Abstract: | In the pivotal WATCHMAN trials, warfarin was used for post-procedural anticoagulation in the first 45 days after left atrial appendage closure. We aimed to investigate the efficacy and safety of direct oral anticoagulant (DOAC) versus warfarin after WATCHMAN. We performed a literature search of 5 electronic databases to identify studies comparing DOAC with warfarin after WATCHMAN. We pooled outcomes for the efficacy (thromboembolism, device-related thrombus DRT], peridevice leak PDL] >5 mm) and safety endpoints (bleeding, mortality). Thromboembolism was defined as ischemic stroke, transient ischemic attack, or systemic embolism. We included 10 cohort studies with 2,440 patients, of whom 1,397 (57.3%) received DOAC. Concerning periprocedural outcomes (within 7 days following implantation), DOAC was associated with a reduction in major bleeding (Risk ratio RR] 0.32; 95% confidence interval CI] 0.11-0.92) compared with warfarin, without significant differences in all bleeding (RR 0.46; 95% CI 0.15-1.42) and thromboembolism (RR 0.93; 95% CI 0.21-4.16). On first follow-up transesophageal echocardiography, DRT (RR 0.79; 95% CI 0.39-1.60) and PDL>5 mm (RR 0.44; 95% CI 0.16-1.20) were comparable among groups. With a mean follow-up of 1.5-12 months, DOAC was associated with reductions in major bleeding (RR 0.52; 95% CI 0.30-0.89) and all bleeding (RR 0.38; 95% CI 0.25-0.58) compared with warfarin. The outcomes of thromboembolism (RR 0.79; 95% CI 0.36-1.73) and all-cause mortality (RR 0.49; 95% CI 0.19-1.28) were not significantly different between the 2 groups. Following WATCHMAN implantation, DOAC was associated with reductions in major bleeding and all bleeding compared with warfarin at mid-term follow-up. The outcomes of thromboembolism, all-cause mortality, DRT, and PDL >5 mm were comparable among groups. |
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