Exclude or Not: What to Do With the Appendage?

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?

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