| Purpose and Background:Atrial fibrillation(AF) is the most common sustained arrhythmia,which has the high risk of thrombosis and sysytemic embolism,especially the stroke. Stroke is a major contributor to morbidity and mortality among atrial fibrillation patients.Nowadays, oral anticoagulation(OAC) has been reconmended to reduce the risk of AF-associated stroke and sysytemic embolism in those at high risk,but as it’s limitation in the narrow therapeutic window bleeding,complexity in monitoring coagulation function and interaction with many food and drugs,not every patient with AF is eliglble to the medicine therapy. Current studies implicated that more than 90%thrombus were founded in the left atrial appendage in nonvalvular atrial fibrillation( NVAF).Because of these,percutaneous LAA closure has been developed as an alternative strategy to overcome the limitations in thromboembolic prophylaxis in NVAF. However, the new technology is still controversy because it’s safty and efficiency drawbacks.According to the recommend of European Society of Car diology(ESC),it is IIb category recommend if the NVAF one in the con train dication of anticoagulation and susceptible to formulating clot.In 2014,the American College of Cardiology(ACC) has the same ranked suggestion in the non-pharmaceutical therapy of NVAF.,meanwhile,adding notes that we can excise LAA during the cardial surgery,that has the evidence of Class C.At present,there are four main kinds of LAACs,the percutaneous LAA transcatheter endocardial occlusion device(PLAATO.Appriva Medical,Inc.Sunnyvale,CA,USA), the Amplatzer cardiac plug(ACP,St,Jude Medical,St.Jude Medical,St.Paul,MN,USA),the Watchman LAA closure device(Boston Scientific,Natick,MA,USA),the LARIAT(Sentre HEAR T.Inc.Redwood City,CA,USA). Only the Watchman device was approved by the Food and Drug Administration(FDA) in March,2015.In order to provide a systematic review and analysis of observational studies on percutaneous left atrial appendage closure(LAAC) for stroke and systemic embolism prophylaxis in NVAF.Methods:A comprehensive search of the Pubmed,Embase,the CENTRAL of Cochrane libary from inception through July 1,2015.Due to lack of a certain amount of randomized comparison clinical trials in the studies of LAAC,we used the incidence rate of patient-year(PY) at first to program a meta-anaylsis,then we used the data on stroke prevention from mutliple large randomized comparison clinical trials(RELY,ROCKET-AF) to produce a hypothetical control group based on clinical variables in the individuals studies.Result:In 24 eligible studies,a total of 1857 devices were planted in 1964 patients with2655 patient years.The mean CHADS2 score was 2.7±0.5.According the single rate meta analysis,the adjusted rate of stroke and systemic embolism is 1.4%PY(95%confidence interval,CI:0.8% to 1.9% PY),comparison with the stroke rate in same level of CHADS2 score(4.0-5.9% PY),there is a remarkable decrease.Summary estimates demonstrate LAAC reduced risk of stroke in comparison with warfarin,the relative risk(RR)1.084,95%CI:0.839-1.339;in comparison with dabigatran,the relative risk(RR)1.206,95%CI:0.993-1.557;in comparison with rivaroxaban,the relative risk(RR)0.064,95%CI:0.050-0.082.The results imply that there are no differences between LAAC and warfarin or dabigatran,there is a tendency of decrease between LAAC and rivaroxaban.Conclusion:1.LAAC can prevent NVAF patients from stroking and can be a reansonable option for stroke prophylaxis in AF when anticoagulation is in contraindications.2.In comparison with warfarin and dabigatran,LAAC has the same efficiency in preventing stroke; In comparison with rivaroxaban,the LAAC is supperior to rivaroxaban.3.More randomized controlled trials are needed to better compare the LAAC and Oral anticoagulation from the efficiency and safty in stroke prevention. |
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