Utilization and Adverse Outcomes of Percutaneous Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation in the United States: Influence of Hospital Volume | Journal Scan

Study Questions:

What are the frequency and predictors of adverse outcomes and costs of the percutaneous left atrial appendage (LAA) closure procedure in the United States?


Data were obtained from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project from 2006-2010. The NIS is the largest all-payer inpatient data set in the United States. Complications were calculated using patient safety indicators and ICD-9-CM codes. Annual hospital volume was calculated using unique hospital identifiers. Weights provided by the NIS were used to generate national estimates.


A total of 268 procedures were analyzed. The overall composite rate of mortality or any adverse event was 24.3%, with 3.4% of patients requiring cardiac surgery post-procedure. Average length of stay (LOS) was 4.61 ± 1.05 days and cost of care was 26,024 ± 34,651. Annual hospital volume was significantly associated with reduced complications and mortality (every unit increase: odds ratio [OR], 0.89; 95% confidence interval [CI], 0.85-0.94; p < 0.001), decrease in LOS (every unit increase: hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.92-0.98; p < 0.001) and cost of care (every unit increase: HR, 0.96; 95%CI, 0.93-0.98; p < 0.001).


The frequency of in-hospital adverse outcomes associated with percutaneous LAA closure is higher in the “real-world” population than in clinical trials. Higher annual hospital volume is associated with safer procedures, lower length of stay, and cost.


The majority of data regarding the safety of percutaneous LAA closure comes from centers with a great deal of experience with the procedure. In those centers, Watchman, LARIAT, and Amplatzer have been shown to be reasonable alternatives to warfarin therapy in patients with atrial fibrillation. This study shows that patients at unselected hospitals have a much higher complication and mortality rate than demonstrated in the clinical trials. However, hospitals with 18 or more LAA closure procedures annually had an overall rate of complications on par with Watchman’s PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial. It would follow that LAA closure procedures should be performed only by centers and operators with high volumes. Unfortunately, this study was not designed to tease out differences in outcomes among the various LAA devices. A payer-mandated registry could facilitate such comparisons and assure continuous quality improvement with these procedures.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Atrial Appendage, Atrial Fibrillation, Cardiac Surgical Procedures, Health Care Costs, Hospitals, High-Volume, International Classification of Diseases, Length of Stay, Patient Safety, Quality Improvement, Registries, Stroke, United States

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