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Surgical LAA Occlusion and AF-Associated Thromboembolism
Study Questions:
What is the association of surgical left atrial appendage occlusion (S-LAAO) versus no receipt of S-LAAO with the risk of thromboembolism among older patients with atrial fibrillation (AF) undergoing cardiac surgery?
Methods:
This was a retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged ≥65 years with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014.
Results:
Among 10,524 patients undergoing surgery (median age, 76 years; 39% female; median CHA2DS2-VASc score 4), 3,892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, and all-cause mortality in 21.5%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs. 6.2%), all-cause mortality (17.3% vs. 23.9%), and the composite endpoint (20.5% vs. 28.7%), but no significant difference in rates of hemorrhagic stroke (0.9% vs. 0.9%). After adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (sub-distribution hazard ratio [HR], 0.67; p < 0.001), all-cause mortality (HR, 0.88; p = 0.001), and the composite endpoint (HR, 0.83; p < 0.001), but not hemorrhagic stroke (HR, 0.84; p = 0.44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2% vs. 6.0%; adjusted HR, 0.26; p < 0.001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1% vs. 6.3%; adjusted HR, 0.88; p = 0.59).
Conclusions:
Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years.
Perspective:
While large randomized trials of a percutaneous LAAO have been published (PROTECT-AF and PREVAIL), S-LAAO outcomes data are limited to diminutive randomized studies as well as nonrandomized and still quite small cohort studies. Thus, in the current guidelines, S-LAAO carries only a Class IIb recommendation when performed with a concomitant heart surgery in patients with AF. The present study examines a large, nationally representative cohort, and it supports the notion that S-LAAO may be of benefit. The study showed that S-LAAO was associated with a lower rate of thromboembolism among patients who were discharged without oral anticoagulation. Among patients on oral anticoagulation, S-LAAO was not associated with thromboembolism, but it was associated with a lower risk for hemorrhagic stroke, likely related to cessation of oral anticoagulation among S-LAAO patients. More definitive data are expected from the ongoing Left Atrial Appendage Occlusion Study (LAAOS) III, a trial in which 4,700 cardiac surgery patients with AF are randomized to S-LAAO versus no S-LAAO with 4 years of planned follow-up and a primary endpoint of stroke or systemic embolism, with oral anticoagulants being recommended in both groups.
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Cardiac Surgical Procedures, Coronary Artery Bypass, Embolism, Geriatrics, Heart Valve Diseases, Hemorrhage, Patient Readmission, Secondary Prevention, Stroke, Thromboembolism
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