Early Discontinuation of Long-Term Anticoagulation After Surgical Left Atrial Appendage Occlusion

BACKGROUND: Surgical left atrial appendage occlusion (sLAAO) is known to prevent strokes in patients with atrial fibrillation (AF). However, for AF patients on long-term anticoagulation (AC), little is known about the safety of AC discontinuation after sLAAO. METHODS: The study included Medicare patients with AF on AC undergoing coronary artery bypass grafting or valve surgery from 2016 to 2019. By propensity score matching, patients who did not continue AC more than 90 days after surgery were compared with patients continuing AC. RESULTS: Of 10,407 patients undergoing sLAAO, 2470 (14.0%) exhibited early AC discontinuation and had 5-year risk of embolic events that was 1% higher (6.3% vs 5.3%; subdistribution hazard ratio [HR], 1.32 [1.05-1.59]; P = .043). However, the risk of major bleeding was much lower in those patients (13.7% vs 17.8%; subdistribution HR, 0.68 [0.57-0.82]; P < .001) such that no difference was observed in the composite outcome of mortality, embolism, or major bleeding (34.0% vs 34.0%; HR, 0.97 [0.86-1.10]; P = .64). Moreover, risk of embolism in sLAAO patients discontinuing AC was no different from that in AF patients continuing AC after surgery who did not undergo sLAAO (6.5% vs 6.5%; HR, 1.20 [0.93-1.47]; P = .18), and the risk of mortality, embolism, or major bleeding was lower (34.5% vs 38.6%; HR, 0.84 [0.74-0.95]; P = .006). CONCLUSIONS: AF patients on long-term AC who underwent sLAAO and discontinued AC after surgery were not at increased composite risk with respect to mortality, embolism, or major bleeding during 5 years. Discontinuation of long-term AC after sLAAO may be associated with acceptable long-term outcomes in many patients.