A 62-year-old male patient with a history of diabetes and permanent atrial fibrillation (AF) (CHA2DS2-VASc score of 3) on apixaban presents with symptomatic severe aortic stenosis with New York Heart Association Class III symptoms and recent heart failure hospitalization. Echocardiography shows left ventricular ejection fraction of 65%, aortic valve area of 0.8 cm2, and mean gradient of 45 mmHg with no other valvular abnormalities. Computed tomography shows a bicuspid aortic valve with calcified right-left raphe and annular/left ventricular outflow tract calcification. Cardiac catheterization shows non-obstructive coronary artery disease. After heart team discussion, the patient is deemed low surgical risk for surgical aortic valve replacement (SAVR), and, due to unfavorable anatomy for transcatheter aortic valve replacement (TAVR), the recommendation is to proceed with SAVR. The patient enquires about the risk of stroke with SAVR and what to do with his permanent AF.
What would you tell the patient regarding the management of his AF and stroke risk?
The correct answer is: C. Recommend combined SAVR and LAA exclusion in light of the most recent clinical data that it would reduce stroke and instruct the patient to remain on anticoagulation.
The LAAOS III (Left Atrial Appendage Occlusion Study)1 randomized controlled trial included 4,770 patients with AF and a CHA2DS2-VASc score ≥2 who underwent cardiac surgery for other indications. Among patients randomized to surgical occlusion of the LAA, risk of stroke and systemic embolism was reduced by 1/3 (hazard ratio 0.67; 95% confidence interval, 0.53-0.85; p = 0.001) over a ~4-year follow-up period. The benefit of LAA occlusion was additive to that of systemic anticoagulation because treating physicians were blinded to treatment group, and 76.8% of participants remained on oral anticoagulants 3 years postoperatively. Given the trial data, one should consider LAA occlusion at the time of SAVR on this patient provided it would not increase the surgical risk to the patient.
A concomitant biatrial Cox-Maze III procedure in a patient with permanent AF may be too aggressive and significantly adds the cross-clamp time and increases the risk of the operation without potential benefit of restoring normal sinus rhythm. Given that this patient is young and has permanent AF with elevated CHA2DS2-Vasc score, his stroke risk with isolated SAVR would not be comparable to TAVR because bicuspid aortic valve patients were excluded from the randomized trials comparing SAVR with TAVR. In addition, current American College of Cardiology and American Heart Association guidelines would recommend this patient to undergo SAVR instead of TAVR. Although consulting an electrophysiologist is reasonable for this patient, again the stroke risk for an isolated SAVR procedure on this patient cannot be compared to a patient undergoing TAVR because he would have not been eligible for the low-risk randomized trial.
Whitlock RP, Belley-Cote EP, Paparella D, et al. Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. N Engl J Med 2021;384:2081-91.