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Currently, no consensus has been established on the most effective antithrombotic therapy to prevent thromboembolic and bleeding events in patients undergoing percutaneous left atrial appendage closure (LAAC) with preprocedural thromboembolic or bleeding events under oral anticoagulation (OAC) therapy. We retrospectively investigated the incidence of device-related thrombosis (DRT), thromboembolic events, and bleeding events in patients who underwent LAAC from September 2019 to October 2022. After categorizing patients into three groups based on preprocedural thromboembolic or bleeding events under OAC therapy, we compared the incidence of DRT and prognosis according to the postprocedural antithrombotic therapy. In patients who received the conventional antithrombotic therapy (OAC with and without single antiplatelet therapy for 45 days after LAAC and dual-antiplatelet therapy from 45 days to 6 months followed by single antiplatelet therapy), preprocedural thromboembolic events despite OAC were independently associated with DRT or postprocedural thromboembolic events at the 3 year follow-up (hazard ratio [HR] 4.55; 95% confidence interval [CI] 1.32–15.6; P  = 0.016), whereas preprocedural bleeding events were independently associated with postprocedural bleeding events (HR 8.01, 95% CI 1.45–58.3; P  = 0.036). Continuation of OAC for 12 months among patients who developed preprocedural thromboembolic events during OAC significantly decreased the incidence of DRT or postoperative thromboembolic events ( P  = 0.002) with no increase in the bleeding events ( P  = 0.522). Preprocedural thromboembolic and bleeding events can predict adverse events after LAAC with the conventional antiplatelet-based antithrombotic therapy. Patients who develop thromboembolic events under continuous OAC may benefit from continuous OAC for 1 year after LAAC.

BackgroundCoaptation gap (CG) is one of the challenging anatomies of mitral transcatheter edge-to-edge repair (TEER), but its impact on patient outcomes is unclear. This study aimed to evaluate the impact of CG on procedural and clinical outcomes in patients with functional mitral regurgitation (MR).MethodsData from 2140 patients undergoing TEER for functional MR were analysed, focusing on the presence of CG, which is a missing leaflet coaptation between the anterior and posterior leaflets during systole. The primary outcome was a composite of death, heart failure hospitalisation and mitral valve reintervention.ResultsOf the 2140 patients, 219 (10%) had CG and 1921 (90%) did not, as assessed by baseline transoesophageal echocardiography. In patients with CG, baseline MR grade and New York Heart Association (NYHA) functional class were more severe, and long/wide clip types were used more frequently. Post-TEER, patients with CG had significantly lower achievement of MR grade ≤2+ (93%) and ≤1+ (65%) compared with patients without CG (97%, p<0.01; 82%, p<0.01, respectively). NYHA functional class at 1 year was similar in both groups. The cumulative incidence of the primary outcome was comparable between CG and non-CG groups (51% vs 53% at 3 years, p=0.71). While residual MR grade 2+ was associated with the higher primary outcome incidence compared with ≤1+ in patients without CG (p<0.01), no significant difference was found in patients with CG (p=0.51).ConclusionCG was associated with less MR reduction but with no clear difference in adverse clinical outcomes after TEER. Similar outcomes between residual MR grade 2+ and ≤1+ in CG patients highlight the importance of procedural endpoint in anatomically challenging cases.Trial registration numberUMIN000023653.

Background and aimsDelayed bleeding after gastric endoscopic submucosal dissection (ESD) in patients receiving anticoagulants remains an unpreventable adverse event. Although direct-acting oral anticoagulants (DOACs) have superior efficacy in preventing thromboembolism, their effects on the occurrence of delayed bleeding remain unclear. This study aimed to elucidate the clinical effect of DOACs on delayed bleeding after gastric ESD.Patients and methodsWe retrospectively examined 728 patients who received anticoagulants and were treated for gastric neoplasms with ESD in 25 institutions across Japan. Overall, 261 patients received DOACs, including dabigatran (92), rivaroxaban (103), apixaban (45) and edoxaban (21), whereas 467 patients were treated with warfarin.ResultsDelayed bleeding occurred in 14% of patients taking DOACs, which was not considerably different in patients receiving warfarin (18%). Delayed bleeding rate was significantly lower in patients receiving dabigatran than in those receiving warfarin and lower than that observed for other DOACs. Multivariate analysis showed that age ≥ 65, receiving multiple antithrombotic agents, resection of multiple lesions and lesion size ≥ 30 mm were independent risk factors, and that discontinuation of anticoagulants was associated with a decreased risk of bleeding. In multivariate analysis among patients taking DOACs, dabigatran therapy was associated with a significantly lower risk of delayed bleeding.ConclusionsThe effects of DOACs on delayed bleeding varied between agents, but dabigatran therapy was associated with the lowest risk of delayed bleeding. Switching oral anticoagulants to dabigatran during the perioperative period could be a reasonable option to reduce the risk of delayed bleeding after gastric ESD.