Oral Anticoagulation Versus Left Atrial Appendage Closure in Active Cancer Patients With Atrial Fibrillation: A Comparative Analysis of Safety and Efficacy

In this video from TCT 2025, JIC speaks with editorial board member Mehmet Cilingiroglu, MD, about his study on atrial fibrillation treatment in patients with cancer.

Transcript:

Hello to everybody from TCT 2025, San Francisco, California. My name is Dr Mehmet, and I work with UT MD Anderson Cancer Center. Our group looks at the patients with cancer who have cardiovascular heart disease, and we have been doing that for the last decade or so. One of the things in cancer patients that stands out is that they are being treated a little bit differently than some other patients that we have because, obviously, they have a cancer going on. And what we have done with our scientific abstract was basically to look at the patients with active cancer who have atrial fibrillation (AFib). What will be the way of treatment for these patients? Will they be better served with oral anticoagulation or will they be better served with left atrial appendage closure (LAAC)?

In a well-balanced patient demographics group, what we found out is that the patients with cancer who have AFib are better served with having their left atrial appendage closed percutaneously (not surgically) because they ended up with having less bleeding; even though they have interruption in their anticoagulation indication for biopsy or surgery or chemotherapy, these patients have much less bleeding. They have much less stroke related to AFib, embolic stroke, and patient satisfaction as well as cost effectiveness are improved. When you look at these patients in the long run, they were better served with closure of their atrial appendage with the WATCHMAN device or the other LAAC devices.

So I think what we get out of this study is that cancer patients in particular are a specific population that, contrary to non-cancer patients, definitely benefits from LAAC, which was associated with less bleeding, less mortality due to overall bleeding, and better patient satisfaction and less stroke.

What prompted you to investigate this particular patient population?

Our group at MD Anderson has a large cancer population and we have been working on investigating the specific treatments in cancer patients, not just in AFib, but also in coronary artery disease, valvular heart disease, peripheral arterial disease, and structural heart disease. But AFib was standing out because these patients also developed (related to chemotherapy and radiation therapy) cardiomyopathy and other things that increase their chance of having AFib besides the conventional risk factors. And these patients get a lot of biopsies, so there is interruption in their anticoagulation, and we all know that if you interrupt the anticoagulation, your risk of embolic stroke goes up. So, we wanted to find out what will be the best treatment for them in both short- and long-term.

What are the unique challenges or considerations associated with treating patients with cancer?

For cancer patients, the heart team communicates with the patient-specific oncologist rather than making decisions independently. We ask: what will be the best for this particular patient?

Can you summarize the most significant safety and efficacy differences you observed between the two treatment strategies, and how these results might influence clinical management decisions for patients with both cancer and atrial fibrillation?

Well, number one, the cancer patients, when they get chemotherapy, unfortunately, they get a reduction in their platelet count, they're prone to bleeding, and some of them may develop pancytopinia or hemoglobin reduction. So what we found out is that, in patients who are prone to bleeding to begin with, if you put them on anticoagulation, it is very hard for them to continue with anticoagulation, including the risk of major bleeding, which is itself associated with increased risk of death. So what we found out is that left atrial appendage closure provides a better outcome with much less bleeding, which translates into a reduction in mortality and morbidity in these patients.

Are there particular subsets of patients, based on cancer type, prognosis, etc, that may benefit from one particular approach over another? And vice versa, are there certain patients who should NOT undergo one treatment vs another?

I think most patients should undergo left atrial appendage closure unless they have solid cancers and treatment is done already—they don't require any more biopsies or surgeries. Maybe they can stay on anticoagulation as long as their platelet count and hemoglobin is normal, maybe they can stay on anticoagulation on the long run, it's the patients' choice. But in patients who have hematologic cancers, such as like leukemia, these patients I think will better be served with left atrial appendage closure.

Do you believe that what you have learned from this study is applicable to other subsets of patients?

In general, in the United States of America, as we get older, we have memory problems, unfortunately, we have risk of GI bleed, we have risk of falling and injuring ourselves, whether it's breaking the hip, whether it's bleeding to the head, and I think as we develop the novel devices that will require no anticoagulation, no antiplatelet therapy, I think left atrial appendage closure will be the way to go, if not all, for most of our patients.

What are the next steps in this line of research—do you plan to explore specific cancer subtypes, treatment regimens, or long-term outcomes to refine patient selection for left atrial appendage closure versus anticoagulation?

Yes, we are planning to look at cancer subtypes, whether it's solid cancer, hematologic cancer, female cancers, ovarian cancers, and further analyze so that we can learn which patient groups will benefit the most.

The transcript has been lightly edited for clarity.