A turning point in anticoagulation vs LAA closure devices?

Worth a read and it's short. This issue could significantly affect your life in the relatively near future if you're on anticoagulants or ever might need to be.

Heart Rhythm Society white paper on LAA closure devices vs. anticoagulants

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The Heart Rhythm Society has published a white paper looking at the consequences of oral anticoagulants for managing stroke risk in atrial fibrillation which suggests that success with left atrial appendage closure (LAAC) device implantation may represent a “turning point in medical practice”.

The panel member and EP who was interviewed claims that a lot of the patients they are taking care of with LAA are pleased that unlike OACs " they don’t have to go back to the emergency room every other week or for a blood transfusion every couple of months". I have not heard this before and I have doubts about its accuracy. My understanding of resistance to OACs was risk of bleeding, monitoring requirements, dietary restrictions, side effects, and cost (not every issue applying to all OACs). If this EP is spouting a lot of exaggerated anecdotes to sell the procedure, then I think it is a bad idea, as the data speaks for itself.

Agree with you, safib. I've cared for, and supervised, numerous patients on OACs through the years.

Weekly ER visits, bi-monthly transfusions??? Never encountered these.

Of course, I'd much rather a non-OAC solution to AF stroke risk... such as a LAA device... but I'm not convinced the above "observations" are real-world occurrences in the US.

/L

While that's pretty extreme for the afib population we know, it's not extreme for a doctor dealing with a very sick population. For example, people with chronic GI bleeding problems might very well find themselves in ERs frequently and receiving transfusions every few months. Imagine that you have persistent afib, a high CHADS-Vasc score, and a chronic GI bleed that leaves you anemic every few months. You can't stop your anticoagulant but it keeps making you slowly bleed out. There are people out there like that so I don't think he's exaggerating to sell anything. His reputation and credentials are pretty impeccable.

He's not stipulating anything about extreme cases. There's no evidence I can find that any sizable percentage of afib patients on OACs because of CHADS-Vasc score experience biweekly ER visits or bimonthly transfusions. Show me the published peer-reviewed statistics. I think it is poor judgment to present OACs in this light, potentially scaring off people from using them. I don't know if he is hyping LAA because of some connection with Boston Scientific but I wouldn't rule it out. I have already experienced someone with far better credentials than this guy hyping FIRM, which fortunately and thanks to Shannon I didn't submit to. I don't want to argue about the point, it seems clear cut to me and others will have to form their own opinion.

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safib
There's no evidence I can find that any sizable percentage of afib patients on OACs because of CHADS-Vasc score experience biweekly ER visits or bimonthly transfusions.

Spend a few years in EMS and you'll come to realize there are a lot more than you think, particularly in nursing homes, but I agree in general. You won't find such data and I'm sure he wouldn't try to say you will. He should have clarified his intent but I don't think his comment deserves such scorn.

I think two things are getting overlooked here. The first is that the HRS white paper wasn't written for an audience of patients. It was written by doctors for doctors. Doctors would have understood his comments about ER visits and transfusions as referring to the subpopulation of afib patients with high bleed risks such as patients with ulcerative colitis, Crohn's disease, ulcers, esophageal varices, cancer, bleeding disorders, arteriovenous malformations, a history of hemorrhagic stroke, and so forth. There actually is a pretty sizable population of patients who can't tolerate anticoagulants well or at all and yet who have afib and need them. Those are shoes you don't want to be in.

The second thing is that those are exactly the patients the LAA closure devices were originally designed for; ie, patients with high stroke risks who can't tolerate anticoagulants. Originally, those were the only candidates for LAA closure devices. So it's not surprising to find a panel addressing LAA closure to focus on that patient population and be discussing things like transfusions and frequent ER visits.

The real turning point they're discussing here is the relatively new finding that LAA closure devices can be appropriate for a wider population. In particular, they're useful for the increasingly large population of ablation patients who required LAA isolation to stop their afib. A large percentage of persistent afibbers fall into this category because isolating the LAA is often necessary to stop persistent afib. Having had my LAA isolated in 2017, I understand this very well. I was told that I had to remain on an OAC for life and that missing even a single dose was hazardous. My discharge instructions had big, bold text highlighted with yellow highlighter that said DO NOT STOP YOUR ANTICOAGULANT FOR ANY REASON.

Think about that for a minute. I was already overdue for a colonoscopy, and I needed hernia repair surgery, but both procedures would require me to stop Eliquis, which I was forbidden from doing. So I would have to go on a heparin bridging protocol to have those procedures, which many surgeons and gastro docs aren't familiar with and will refuse to even consider. And what are the odds that in the next 20-25 years I will never need surgery, have a serious accident, or even just find myself somewhere without my supply and no way to obtain more quickly?

My estimation was the odds were very, very low that I could spend the rest of my life on Eliquis without interruption for even a single day. I give that about zero chance. So I leaped at the opportunity to join the Watchman FLX trial and have one implanted. So now I am free of anticoagulants, quite probably for life. I had my hernia repair surgery last December and I had my colonoscopy last week, two things I couldn't have easily done without the Watchman.



Edited 1 time(s). Last edit at 06/14/2019 04:56PM by Carey.