The need for anticoagulation following left atrial appendage (LAA) ligation in patients with atrial fibrillation (AF) is determined by several factors, including the patient's overall stroke risk, the success of the LAA occlusion, and the presence of other potential causes for stroke other than AF
Stroke risk assessment
- The stroke risk in patients with AF is often assessed using the CHA₂DS₂-VASc score, which considers factors such as congestive heart failure, hypertension, age, diabetes, and prior stroke or transient ischemic attack (TIA)
- Patients with a high CHA₂DS₂-VASc score (2 in men or 3 in women) may still require anticoagulation therapy even after successful LAA ligation. Conversely, patients with a low CHA₂DS₂-VASc score (0 in men or 1 in women) might not need continued anticoagulation.
Success of LAA occlusion
- The success of the LAA occlusion is a critical factor. Incomplete occlusion or residual leaks may necessitate continued anticoagulation.
- Follow-up imaging, such as transesophageal echocardiography (TEE) or cardiac CT, is often recommended to assess the success of the procedure and guide further management.
Other potential causes for stroke
- It is important to identify and treat other potential causes for stroke beyond AF, and promote general vascular risk factor modification and healthy lifestyle choices
- For instance, patients with AF-associated stroke despite oral anticoagulation are much more likely than patients who are anticoagulant naïve to have competing stroke mechanisms, such as small vessel occlusion and arterial atheroma
Guidelines and recommendations
- The ACC/ACCP/AHA/HRS 2024 guidelines recommend performing surgical LAA exclusion, in addition to continued anticoagulation, to reduce the risk of stroke and systemic embolism in patients with AF undergoing cardiac surgery with a CHA₂DS₂-VASc score ≥ 2 or equivalent stroke risk
- However, the same guidelines also state that there is insufficient evidence to recommend surgical LAA exclusion without continued anticoagulation to reduce the risk of stroke and systemic embolism in patients with AF undergoing cardiac surgery with a CHA₂DS₂-VASc score ≥ 2 or equivalent stroke risk
- The EACTS/ESC 2021 guidelines suggest performing LAA occlusion for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment (such as intracranial bleeding without a reversible cause)
In conclusion, the decision to continue anticoagulation therapy post-LAA ligation in AF patients should be individualized, taking into account the patient's overall stroke risk, the success of the LAA occlusion, and the presence of other potential causes for stroke other than AF