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Reduced Rivaroxaban Dose Versus Dual Antiplatelet Therapy After Left Atrial Appendage Closure: ADRIFT a Randomized Pilot Study

Guillaume Duthoit 1, 2 Johanne Silvain 1, 2 Eloi Marijon 3 Gregory Ducrocq 4 Antoine Lepillier 5 Corinne Frere 2 Solohaja Faniaha Dimby 6 Batric Popovic 7 Nicolas Lellouche 8 Isabelle Martin-Toutain 1 Christian Spaulding 3 Eric Brochet 9 David Attias 5 Jacques Mansourati 10 Luc Lorgis 11 Didier Klug 12 Noura Zannad 13 Marie Hauguel-Moreau 14 Nassim Braik 1, 2 Sandrine Deltour 15 Alexandre Ceccaldi 2, 1 Hui Wang 16 Nadjib Hammoudi 1, 2 Delphine Brugier 1, 2 Eric Vicaut Jean-Michel Juliard 4 Gilles Montalescot 1, 2 
Abstract : Background: Percutaneous left atrial appendage closure (LAAC) exposes to the risk of device thrombosis in patients with atrial fibrillation who frequently have a contraindication to full anticoagulation. Thereby, dual antiplatelet therapy (DAPT) is usually preferred. No randomized study has evaluated nonvitamin K antagonist oral anticoagulant after LAAC, and we decided to evaluate the efficacy and safety of reduced doses of rivaroxaban after LAAC. Methods: ADRIFT (Assessment of Dual Antiplatelet Therapy Versus Rivaroxaban in Atrial Fibrillation Patients Treated With Left Atrial Appendage Closure) is a multicenter, phase IIb study, which randomized 105 patients after successful LAAC to either rivaroxaban 10 mg (R10, n=37), rivaroxaban 15 mg (R15, n=35), or DAPT with aspirin 75 mg and clopidogrel 75 mg (n=33). The primary end point was thrombin generation (prothrombin fragments 1+2) measured 2 to 4 hours after drug intake, 10 days after treatment initiation. Thrombin-antithrombin complex, D-dimers, rivaroxaban concentrations were also measured at 10 days and 3 months. Clinical end points were evaluated at 3-month follow-up. Results: The primary end point was reduced with R10 (179 pmol/L [interquartile range (IQR), 129–273], P<0.0001) and R15 (163 pmol/L [IQR, 112–231], P<0.0001) as compared with DAPT (322 pmol/L [IQR, 218–528]). We observed no significant reduction of the primary end point between R10 and R15 while rivaroxaban concentrations increased significantly from 184 ng/mL (IQR, 127–290) with R10 to 274 ng/mL (IQR, 192–377) with R15, P<0.0001. Thrombin-antithrombin complex and D-dimers were numerically lower with both rivaroxaban doses than with DAPT. These findings were all confirmed at 3 months. The clinical end points were not different between groups. A device thrombosis was noted in 2 patients assigned to DAPT. Conclusions: Thrombin generation measured after LAAC was lower in patients treated by reduced rivaroxaban doses than DAPT, supporting an alternative to the antithrombotic regimens currently used after LAAC and deserves further evaluation in larger studies.
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Submitted on : Saturday, July 25, 2020 - 11:42:16 AM
Last modification on : Thursday, December 1, 2022 - 12:27:54 PM

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Guillaume Duthoit, Johanne Silvain, Eloi Marijon, Gregory Ducrocq, Antoine Lepillier, et al.. Reduced Rivaroxaban Dose Versus Dual Antiplatelet Therapy After Left Atrial Appendage Closure: ADRIFT a Randomized Pilot Study. Circulation: Cardiovascular Interventions, 2020, 13 (7), pp.e008481. ⟨10.1161/CIRCINTERVENTIONS.119.008481⟩. ⟨hal-02906699⟩



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