This trial is designed to examine the hypothesis that thoracoscopic LAA clipping is superior to NOACs for stroke, systemic embolism, all-cause mortality, major bleeding events and clinically relevant nonmajor bleeding events in AF patients at high risk of embolism (CHA2DS2-VASc ≥2 in men and ≥3 in women) that are not undergoing ablation.
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia disease, and the incidence of AF increases markedly with age and approximately doubles with each decade. According to the previous study, the incidence of stroke were five times in patients with AF than those in the general population. Systemic oral anticoagulant is a well-established, guideline-recommended therapy for the prevention of ischemic stroke in patients with nonvalvular AF at high risk of embolism (CHA2DS2-VASc scores ≥2 in men and ≥3 in women), and the guidelines recommend that the novel oral anticoagulants (NOACs) be preferred (Class I, Level of evidence A). However, a significant proportion of patients with nonvalvular AF have difficulties in long-term oral anticoagulant therapy, due to medication adherence and contraindications to oral anticoagulants. Also, several randomized controlled trials indicated that bleeding risk remained high with novel oral anticoagulants. Therefore, it is essential to explore alternative treatment strategies for stroke prevention in patients with nonvalvular AF. It has been reported that the left atrial appendage (LAA) is suspected as a vital source of cerebral emboli and may lead to ischemic stroke, removal or closure of the LAA may be an alternative to oral anticoagulants. Various surgical or interventional approaches have been developed to close or occlude LAA to prevent stroke in AF patients, such as percutaneous LAA occlusion, suture ligation, and surgical excision. However, these techniques suffer from incomplete LAA closure or the presence of residual blood flow, which can lead to thrombosis and stroke. Thoracoscopic LAA clip, on the other hand, cloud block blood flow between the LAA and the left atrium (LA), achieving isolation of LAA and preventing thrombi and strokes. A previous study has demonstrated a high 95% success rate of LAA clipping without operation-related complications, and freedom from stroke was 99.1% at a median follow-up of 20 months. Therefore, LAA clipping is an effective and durable method in stroke prevention. However, currently high-quality RCTs are lacking to support the superiority of LAA clipping compared with NOACs in terms of stroke prevention and safety. In this trial, the investigators designed a multicenter prospective RCT to compare the efficacy and safety of thoracoscopic LAA clipping and NOACs in patients with non-paroxysmal AF.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
SINGLE
Enrollment
290
The surgeons measured the length of the base of the LAA, an appropriately sized LAA clip is then inserted with the aid of a thoracoscope and placed parallel to the base of the LAA.
For patients with creatinine clearance ≥50 ml/min, oral rivaroxaban 20 mg daily was administered, whereas for patients with creatinine clearance between 30-49 ml/min, oral rivaroxaban 15 mg daily was administered.
China National Center for Cardiovascular Diseases
Beijing, Beijing Municipality, China
RECRUITINGRate of composite endpoint
Stroke, systemic embolism, all-cause mortality, major bleeding event, and clinically relevant non-major bleeding event.
Time frame: At 24-month after intervention
Rate of stroke
Acute episodes of focal or global neurological dysfunction due to cerebral, spinal cord or retinal vascular injury from haemorrhage or infarction. Symptoms or signs must have lasted ≥ 24 hours, or symptoms/signs may have lasted less than 24 hours if demonstrated by CT, MRI, or autopsy.
Time frame: At 24-month after intervention
Rate of systemic embolism
Confirmed by imaging or angiography
Time frame: At 24-month after intervention
Rate of all-cause mortality
Deaths from all causes
Time frame: At 24-month after intervention
Rate of major bleeding event
1. fatal haemorrhage, and/or 2. Symptomatic haemorrhage in a critical area or organ, such as intracranial, intravertebral, intraocular, retroperitoneal, intra-articular or intrapericardial, or intramuscular haemorrhage leading to osteofascial compartment syndrome, and/or 3. haemorrhage that results in a fall in haemoglobin level of 2.0 g/dL or more, or that results in the importation of two or more units of whole blood or red blood cells.
Time frame: At 24-month after intervention
Rate of clinically relevant non-major bleeding event
Bleeding events that do not meet the criteria for an ISTH major bleeding event but requires hospitalisation or a change in antithrombotic treatment strategy or requires invasive management.
Time frame: At 24-month after intervention
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Rate of surgery-related complications
Incidence of in-hospital death, in-hospital stroke, intermediate small-incision open thoracotomy or median open thoracotomy, and postoperative re-intervention due to hemorrhage, pneumothorax, and pyothorax.
Time frame: At 24-month after intervention
Rate of minor bleeding events
Bleeding events that do not meet the ISTH criteria for a major bleeding event, do not meet the criteria for a clinically relevant non-major bleeding event, and do not require the subject to seek additional assistance from medical care.
Time frame: At 24-month after intervention