LA Appendage Occlusion Reduces Post-Cardiac Surgery Thromboembolism Risk
Risk for thromboembolic stroke is increased in individuals with atrial fibrillation.
Surgical left atrial appendage occlusion (S-LAAO) is associated with a reduced risk for thromboembolism-related readmission over a 3-year period in older patients with atrial fibrillation, according to a retrospective analysis published in JAMA.
Using a study cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (N=10,524), investigators retrospectively compared outcomes of patients aged ≥65 years with atrial fibrillation who had received concomitant S-LAAO (n=3892) vs those who did not receive S-LAAO (n=6632). All participants underwent either coronary artery bypass grafting (CABG), aortic valve surgery with or without CABG, or mitral valve surgery with or without CABG.
The 3-year readmission for thromboembolism, which consisted of either stroke, systemic embolism, or transient ischemic attack, comprised the primary outcome. Additionally, the investigators compared patients receiving S-LAAO vs those not receiving S-LAAO in regard to the incidence of hemorrhagic stroke, all-cause mortality, and a composite end point of hemorrhagic stroke, all-cause mortality, or thromboembolism.
In the crude analysis, S-LAAO was associated with significantly lower rates of all-cause mortality (17.3% vs 23.9%; hazard ratio [HR] 0.70; 95% CI, 0.64-0.77; P <.001), thromboembolism (4.2% vs 6.2%; HR 0.66; 95% CI, 0.56-0.79; P <.001), and the composite end point (20.5% vs 28.7%; HR 0.69; 95% CI, 0.63-0.75; P <.001), with no differences observed between the 2 groups in terms of hemorrhagic stroke (0.9% vs 0.9%; HR 0.97; 95% CI, 0.64-1.45; P =.86).
Adjusted analysis revealed that the superiority of concomitant S-LAAO vs no S-LAAO persisted, with significantly lower rates of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95% CI, 0.56-0.81; P <.001), all-cause mortality (HR, 0.88; 95% CI, 0.79-0.97; P =.001), and the composite end point (HR, 0.83; 95% CI, 0.76-0.91; P <.001) observed among the S-LAAO arm. No reduction in the risk for hemorrhagic stroke with S-LAAO vs no S-LAAO was seen following inverse probability-weighted adjustment (subdistribution HR, 0.84; 95% CI, 0.53-1.32; P =.44).
Among patients discharged without anticoagulation, concomitant S-LAAO correlated with a lower thromboembolism risk compared with no S-LAAO (unadjusted rate, 4.2% vs 6.0%, respectively; adjusted subdistribution HR, 0.26; 95% CI, 0.17-0.40; P <.001). This association did not translate over to patients who were discharged with anticoagulation therapy (unadjusted rate, 4.1% vs 6.3%; adjusted subdistribution HR, 0.88; 95% CI, 0.56-1.39; P =.59).
Limitations of the study include its nonrandomized and observational design as well as the limited generalizability of the findings to younger patients.
The investigators concluded that their “analysis supports the use of S-LAAO in patients with [atrial fibrillation] at the time of cardiac surgery.”
Friedman DJ, Piccini JP, Wang T, et al. Association between left atrial appendage occlusion and readmission for thromboembolism among patients with atrial fibrillation undergoing concomitant cardiac surgery. JAMA. 2018;319(4):365-374.