A device implanted in the heart using minimally invasive techniques may replace the most widely prescribed drug for stroke prevention in patients with nonvalvular atrial fibrillation, according to research presented during the i2 Summit at the American College of Cardiology’s 58th Annual Scientific Session in Orlando, USA.
In the PROTECT AF (Embolic protection in patients with atrial fibrillation) trial, researchers compared the current standard of therapy, anticoagulation with warfarin, to a fabric-covered expandable nitinol cage known as the Watchman, which blocks blood clots that typically form in the left atrial appendage (LAA), an outpouching of the left atrium. They found that the Watchman reduced by some 30% the combined risk of cardiovascular death and stroke (both ischaemic and haemorrhagic.
“Patients with atrial fibrillation have a six-fold increased risk of stroke and therefore require long-term anticoagulation therapy,” said David R Holmes, Mayo Graduate School of Medicine, Rochester, USA. “The placement of this device results in excellent long-term outcomes – effective ischaemic stroke prevention with the elimination of haemorrhagic strokes and major bleeding often associated with the use of warfarin.”
The Watchman is guided into the heart through a catheter inserted in a vein in the upper leg. The catheter is threaded first into the right atrium, then into the left atrium through a puncture in the wall separating the two upper chambers of the heart. Once the catheter is positioned in the opening of LAA, the Watchman is released and left permanently in place to block the formation and release of blood clots.
For the PROTECT AF study, 707 patients with nonvalvular atrial fibrillation were randomly assigned to closure of the LAA with Watchman (n=463), followed by discontinuation of warfarin, or to long-term treatment with warfarin (n=244). The study found in over 900 patient-years of follow-up that the combined rate of stroke (ischaemic and haemorrhagic) and cardiovascular death – the primary measures of effectiveness – was 3.4 per 100 patient-years in the device group vs. 5 per 100 patient-years in the warfarin group, a reduction of 32% (relative risk [RR], .68).
As for the safety of the device, the researchers observed more procedure-related complications in patients treated with the device (8.7 vs. 4.2 per 100 patient-years; RR, 2.08). Most complications were related to device implantation. However, after successful implantation of the Watchman and discontinuation of warfarin therapy, complication rates were significantly lower with device therapy (1.7 vs. 4.2 per 100 patient-years; RR, .40).
The researchers concluded that the Watchman is an effective alternative to warfarin therapy for preventing stroke in patients with atrial fibrillation. “The take-home message is that although there are complications associated with implantation of the device, patients can avoid the need for chronic warfarin therapy, with all its attendant risks,” Holmes said.
