July 13, 2022Heart

Left atrial appendage preservation versus closure during surgical ablation of atrial fibrillation

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Why the study?

Evidence was limited regarding whether left atrial appendage closure during surgical ablation of AF yields superior clinical outcomes compared with preservation.

Does left atrial appendage closure compared to preservation reduce stroke and mortality in patients undergoing surgical ablation of atrial fibrillation during cardiac surgery?

Structured PICO

Does left atrial appendage closure compared to preservation reduce stroke and mortality in patients undergoing surgical ablation of atrial fibrillation during cardiac surgery?

Population

1640 patients (aged 58.8±11.5 years, 898 women) undergoing surgical ablation of atrial fibrillation during cardiac surgery (mitral valve n=1378; non-MV n=262) between 2001 and 2018.

Intervention

Left atrial appendage (LAA) closure during surgical ablation of atrial fibrillation

Comparator

Left atrial appendage (LAA) preservation

Outcome

Risk of stroke and mortalityhard clinical

LAA preservation during surgical AF ablation is not associated with increased stroke or mortality risk compared to closure, and may preserve postoperative LA transport function.

Implication

LAA preservation appears safe for stroke and mortality after surgical AF ablation; leaves open prospective trials on atrial function.

Abstract

OBJECTIVE: There is limited evidence regarding the effectiveness of left atrial appendage (LAA) closure during surgical ablation of atrial fibrillation (AF) in yielding superior clinical outcomes. This study aimed to evaluate the association of LAA closure versus preservation with the risk of adverse clinical outcomes among patients undergoing surgical ablation during cardiac surgery. METHODS: We evaluated 1640 patients (aged 58.8±11.5 years, 898 women) undergoing surgical ablation during cardiac surgery (including mitral valve (MV), n=1378; non-MV, n=262) between 2001 and 2018. Of these, 804 had LAA preserved, and the remaining 836 underwent LAA closure. Comparative risks of stroke and mortality between the two groups were evaluated after adjustments with inverse-probability-of-treatment weighting (IPTW). Longitudinal echocardiographic data (n=9674, 5.9/patient) on transmitral A-wave and E/A-wave ratio were analysed by random coefficient models. RESULTS: Adjustment with IPTW yielded patient cohorts well-balanced for baseline profiles. During a median follow-up of 43.5 months (IQR 19.0-87.3 months), stroke and death occurred in 87 and 249 patients, respectively. The adjusted risk of stroke (HR 0.85; 95% CI 0.52-1.39) and mortality (HR 0.80; 95% CI 0.61 to 1.05) did not differ significantly between the two groups. Echocardiographic data demonstrated higher transmitral A-wave velocity (group-year interaction, p=0.066) and lower E/A-wave ratio (group-year interaction, p=0.045) in the preservation group than in the closure group. CONCLUSIONS: LAA preservation during surgical AF ablation was not associated with an increased risk of stroke or mortality. Postoperative LA transport functions were more favourable with LAA preservation than with LAA closure.