Efficacy and safety of left atrial appendage occlusion in atrial fibrillation patients with chronic kidney disease: a systematic review and meta-analysis

doi:10.31083/j.rcm.2020.03.62

Reviews in Cardiovascular Medicine

2020, Vol. 21

Issue (3): 443-451 DOI: 10.31083/j.rcm.2020.03.62

Systematic Review

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Efficacy and safety of left atrial appendage occlusion in atrial fibrillation patients with chronic kidney disease: a systematic review and meta-analysis

Hai-Fu Zhang^1,², Qin-Xia Zhang², Yuan-Yuan Zhang¹, Dong Yang¹, Zhao Xu¹, Qi-Bin Jiao^1,², Xing-Wei Zhang^1,^2,^*(

)

¹Division of Cardiology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, P. R. China
²School of Medicine, Hangzhou Normal University, Hangzhou 311121, P. R. China

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Abstract:

Atrial fibrillation (AF) is the most common arrhythmia among the elderly, and more frequently occur in those with chronic kidney disease (CKD). Left atrial appendage occlusion (LAAO) is used as a mechanical alternative approach for prevention of AF-related thromboembolisms. This meta-analysis was conducted to provide suggestions for the clinical application of LAAO in AF patients with CKD. The incidence of perioperative adverse events and other clinical effects after operation was by a single rate meta-analysis. Results showed that incidence of adverse events in the perioperative period after LAAO was generally low, with only pericardial effusion / tamponade (1.90%) and mortality rate (1.10%). During the follow-up period, the incidence of stroke/transient ischemic attack (TIA) and bleeding were 2.17% and 4.53%, respectively. A low incidence rate of adverse events was found in the perioperative period following LAAO. These results indicate that LAAO more effectively prevents the occurrence of stroke/TIA and minimizes bleeding events than oral anticoagulants.

Key words: Atrial fibrillation chronic kidney disease left atrial appendage occlusion

Submitted: 15 April 2020 Revised: 24 July 2020 Accepted: 27 July 2020 Published: 30 September 2020

Fund:
LQ18H020006/Natural Science Foundation of Zhejiang Province of China
0020190126/Health and Technology Plan of Hangzhou City
2017ZD02/Health and Technology Plan of Hangzhou City

^*Corresponding Author(s): Xing-Wei Zhang E-mail: xwzhang@hznu.edu.cn

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Cite this article:

Hai-Fu Zhang, Qin-Xia Zhang, Yuan-Yuan Zhang, Dong Yang, Zhao Xu, Qi-Bin Jiao, Xing-Wei Zhang. Efficacy and safety of left atrial appendage occlusion in atrial fibrillation patients with chronic kidney disease: a systematic review and meta-analysis. Reviews in Cardiovascular Medicine, 2020, 21(3): 443-451.

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https://rcm.imrpress.com/EN/10.31083/j.rcm.2020.03.62 OR https://rcm.imrpress.com/EN/Y2020/V21/I3/443

Fig. 1. Preferred reporting items for systematic reviews and meta-analyses flow diagram. Using different keywords, a total of 1829 articles were retrieved. Through reading title, abstract and full-text, there were 7 relevant articles finally included in our meta-analysis. CKD: chronic kidney disease.

Fig. 2. Quality evaluation char. Select bias and performance bias were higher because of the inclusion of non-randomized controlled trial.

Table 1. Characteristics of 7 studies included in the review

Study	Study design	Age	Male (%)	CHADS-VASc/CHADS	HAS-BLED	Treatment group (n)	Renal function	Previous Stroke/TIA (%)	Previous Major Bleeding (%)
Luani et al. (2019)	cohort study	75.9 $\pm$ 6.7	57.5	4.5 $\pm$ 1.4	3.6 $\pm$ 1.0	Watchman: 73	eGFR $<$ 60 mL/min	16.4	/
Kefer et al. (2016)	RCT	77.9 $\pm$ 7.3	54.7	4.9 $\pm$ 1.5	3.4 $\pm$ 1.3	ACP: 375	eGFR $<$ 60 mL/min	32.3	49.1
Brockmeyer et al. (2019)	cohort study	78.2 $\pm$ 7.3	49.4	4.7 $\pm$ 1.3	3.9 $\pm$ 0.9	ACP: 61 Watchman: 5 Amplatzer Amulet: 14	eGFR $<$ 60 mL/min	17.3	39.6
Genovesi et al. (2018)	prospective cohort study	71.8 $\pm$ 9.6	76	4.0 $\pm$ 1.5	4.4 $\pm$ 0.9	Watchman: 24 Amplatzer Amulet: 26	eGFR $<$ 15 mL/min, on dialysis	20	66
Xue et al. (2018)	RCT	77.0 $\pm$ 7.2	60.9	4.3 $\pm$ 1.5	4.0 $\pm$ 1.0	Watchman: 151	eGFR $<$ 60 mL/min	11.3	25.8
So et al. (2018)	retrospective study	72 $\pm$ 8	65.3	5.1 $\pm$ 1.5	3.4 $\pm$ 0.1	ACP/Amulet: 71	eGFR $<$ 60 mL/min	/	/
Della Rocca et al. (2018)	cohort study	77 $\pm$ 7	46.1	4.9 $\pm$ 1.8	3.7 $\pm$ 0.9	104	eGFR $<$ 60 mL/min	/	/
NOTE: RCT: randomized controlled trial; eGFR: estimated glomerular filtration rate; TIA: transient ischemic attack.

Fig. 3. Forest plots showing the effect of clinical outcomes on the overall risk of perioperative death, stroke/ transient ischemic attack, bleeding, pericardial effusion/tamponade. A total of 7 studies were included. During the perioperative period, mortality rate was 1.10% (OR:0.01, 95%CI: 0.00-0.05). The incidence of stroke/TIA and bleeding in the perioperative period was 1.40% (OR:0.02, 95%CI: 0.01-0.03) and 1.60% (OR:0.02,95%CI: 0.00-0.13). The pericardial effusion/tamponade rate was 1.90% (OR:0.02, 95%CI: 0.00-0.10).

Fig. 4. A forest plot showing the effect of left atrial appendage occlusion on the overall risk of stroke/ transient ischemic attack, bleeding, all-cause death and cardiogenic death in the follow up time. A total of 6 studies were included. The incidence of stroke/TIA and bleeding in the follow up time was 2.17% (OR:0.03, 95%CI: 0.02-0.05) and 4.53% (OR:0.04, 95%CI: 0.02-0.07). All-cause mortality was 12.28% (OR:0.12, 95%CI: 0.09-0.17), and the cardiogenic mortality rate was 3.98% (OR:0.04, 95%CI: 0.03-0.07) during follow-up.

Fig. 5. Forest plots of the meta-analysis comparing the clinical outcomes after left atrial appendage occlusion in patients with or without chronic kidney disease. Patients with CKD exhibited higher all-cause mortality rate after undergoing LAAO (RR:2.00; 95%CI: 1.09-3.68, P

<

0.05). There were no significant differences in stroke/TIA (RR: 0.52, P = 0.24), bleeding (RR: 1.02,

P

= 0.96) and cardiac death (RR: 1.34, P = 0.65).

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