Left Atrial Appendage Occlusion Compared to Anticoagulation in Patients Suffering from Atrial Fibrillation with Advanced Chronic Kidney Disease

<b>Background/Objectives</b>: Chronic kidney disease (CKD) is a significant risk factor for thrombogenic and bleeding events in patients with atrial fibrillation (AF). Left atrial appendage occlusion (LAAO) is increasingly utilized as an alternative to oral anticoagulation. We aimed to compare LAAO against medical therapy in advanced CKD patients (A-CKD). <b>Methods</b>: We conducted a retrospective cohort study to compare patients with AF who had undergone LAAO (intervention group) or patients receiving oral anticoagulation (OAC) (control group). All of them had the diagnosis of A-CKD (estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m²). The primary endpoint was a composite of stroke, transient ischemic attack (TIA), systemic embolism (SE), and major bleeding. Secondary endpoints included: an efficacy combined endpoint (a composition of stroke, TIA, and SE); major bleedings (defined as Bleeding Academic Research Consortium (BARC) ≥ 3), and mortality at follow-up. A propensity score matching was used to balance the populations. <b>Results</b>: In total, 81 and 102 patients composed the LAAO and anticoagulation groups. Mean age was 78.27 ± 10.3 and 81.2 ± 9.07 (<i>p</i> = 0.069) and female sex was 38.3% and 44.1%, respectively. Patients who underwent LAAO had a higher HAS-BLED score: 3.46 ± 0.85 vs. 3.77 ± 1.06, <i>p</i> = 0.011. Median follow-up was 19.0 months [IQR: 10.9-33.5]. There were no differences in the primary combined endpoint at 3-years follow-up-22.2% vs. 34.2% (hazard ratio (HR) 0.63, CI-95%: 0.353-1.11, <i>p</i> = 0.102)-nor respecting the efficacy combined endpoint: 3.7% vs. 6.9% (HR 0.54, CI-95%: 0.14-2.09, <i>p</i> = 0.355). Patients under anticoagulation treatment did present major bleedings (BARC ≥ 3) more often than the intervention group: 38.3%vs50% (HR 0.52, CI-95%: 0.28-0.96, <i>p</i> = 0.031). A total of 15 patients (14.7%) from the control group underwent LAAO during follow-up. After a propensity score matching analysis, the primary combined endpoint was more frequent in the control group (HR 0.47, CI-95%: 0.25-0.90, <i>p</i> = 0.019). <b>Conclusions</b>: Compared with oral anticoagulation therapy, LAAO had no differences in efficacy, but fewer major bleeding rates were found.