Journal
EUROPEAN HEART JOURNAL
Volume 37, Issue 46, Pages 3470-3482APublisher
OXFORD UNIV PRESS
DOI: 10.1093/eurheartj/ehw048
Keywords
Atrial fibrillation; Stroke prevention; Left atrial appendage; Anticoagulation; Health economics
Categories
Funding
- Boston Scientific
- NIHR Cardiovascular Biomedical Research Unit at the Royal Brompton & Harefield NHS Foundation Trust
- Imperial College London
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Aims The aim of this study was to analyse randomized controlled study and real-world outcomes of patients with non-valvular atrial fibrillation (NVAF) undergoing left atrial appendage closure (LAAC) with theWatchman device and to compare costs with available antithrombotic therapies. Methods and results Registry data of LAAC from two centres were prospectively collected from 110 patients with NVAF at risk of stroke, suitable and unsuitable for long-term anticoagulation (age 71.3 +/- 9.2 years, CHADS2 2.8 +/- 1.2, CHA2DS2-VASc 4.5 +/- 1.6, and HAS-BLED 3.8 +/- 1.1). Outcomes from PROTECT AF and registry study LAAC were compared with warfarin, dabigatran, rivaroxaban, apixaban, aspirin, and no treatment using a network meta-analysis. Costs were estimated over a 10-year horizon. Uncertainty was assessed using sensitivity analyses. The procedural success ratewas 92% (103/112). Follow-up was 24.1 +/- 4.6 months, during which annual rates of stroke, major bleeding, and all-cause mortality were 0.9% (2/223 patient-years), 0.9% (2/223 patient-years), and 1.8% (4/223 patient-years), respectively. Anticoagulant therapy was successfully stopped in 91.2% (93/102) of implanted patients by 12 months. Registry study LAAC stroke and major bleeding rates were significantly lower than PROTECT AF results: mean absolute difference of stroke, 0.89% (P = 0.02) and major bleeding, 5.48% (P, 0.001). Left atrial appendage closure achieved cost parity between 4.9 years vs. dabigatran 110 mg and 8.4 years vs. warfarin. At 10 years, LAAC was cost-saving against all therapies (range 1162- pound 7194) pound. Conclusion Left atrial appendage closure in NVAF in a real-world setting may result in lower stroke and major bleeding rates than reported in LAAC clinical trials. Left atrial appendage closure in both settings achieves cost parity in a relatively short period of time and may offer substantial savings compared with current therapies. Savings are most pronounced among higher risk patients and those unsuitable for anticoagulation.
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