Key result
Surgical LAA occlusion cuts stroke or systemic embolism ~30%, even with continuous OAC therapy.
Why the study?
It was unknown how variation in oral anticoagulant therapy affects the stroke-reduction benefit of left atrial appendage occlusion in patients with atrial fibrillation undergoing cardiac surgery.
Does surgical left atrial appendage occlusion reduce ischemic stroke or systemic embolism in patients with atrial fibrillation undergoing cardiac surgery, independent of oral anticoagulation use?
RCT (n=4,760)
Double-blind
Randomized
Yes
Does surgical left atrial appendage occlusion reduce ischemic stroke or systemic embolism in patients with atrial fibrillation undergoing cardiac surgery, independent of oral anticoagulation use?
Hazard Ratio: 0.7 (95% CI 0.51–0.96)
Absolute Event Rate: 1.2% vs 1.7%
Surgical left atrial appendage occlusion provides protection against ischemic stroke and systemic embolism in patients with atrial fibrillation, and this benefit is consistent regardless of whether patients are receiving oral anticoagulation therapy.
Supports surgical LAA occlusion irrespective of OAC in AF patients undergoing cardiac surgery; extends LAAOS III by confirming consistent benefit on anticoagulation.
BACKGROUND: LAAOS III (Left Atrial Appendage Occlusion Study III) showed that left atrial appendage (LAA) occlusion reduces the risk of ischemic stroke or systemic embolism in patients with atrial fibrillation undergoing cardiac surgery. This article examines the effect of LAA occlusion on stroke reduction according to variation in the use of oral anticoagulant (OAC) therapy. METHODS: Information regarding OAC use was collected at every follow-up visit. Adjusted proportional hazards modeling, including using landmarks of hospital discharge, 1 and 2 years after randomization, evaluated the effect of LAA occlusion on the risk of ischemic stroke or systemic embolism, according to OAC use. Adjusted proportional hazard modeling, with OAC use as a time-dependent covariate, was also performed to assess the effect of LAA occlusion, according to OAC use throughout the study. RESULTS: At hospital discharge, 3027 patients (63.5%) were receiving a vitamin K antagonist, and 879 (18.5%) were receiving a non-vitamin K antagonist oral anticoagulant (direct OAC), with no difference in OAC use between treatment arms. There were 2887 (60.5%) patients who received OACs at all follow-up visits, 1401 (29.4%) who received OAC at some visits, and 472 (9.9%) who never received OACs. The effect of LAA occlusion on the risk of ischemic stroke or systemic embolism was consistent after discharge across all 3 groups: hazard ratios of 0.70 (95% CI, 0.51-0.96), 0.63 (95% CI, 0.43-0.94), and 0.76 (95% CI, 0.32-1.79), respectively. An adjusted proportional hazards model with OAC use as a time-dependent covariate showed that the reduction in stroke or systemic embolism with LAA occlusion was similar whether patients were receiving OACs or not. CONCLUSIONS: The benefit of LAA occlusion was consistent whether patients were receiving OACs or not. LAA occlusion provides thromboembolism reduction in patients independent of OAC use.
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Connolly et al. (2023) conducted an RCT in Atrial fibrillation (n=4,760). Left atrial appendage occlusion vs. No left atrial appendage occlusion was evaluated on Ischemic stroke or systemic embolism (patients receiving OACs at all visits) (HR 0.70, 95% CI 0.51-0.96). Left atrial appendage occlusion reduced the risk of ischemic stroke or systemic embolism independently of oral anticoagulant use, with a consistent benefit (HR 0.70) observed even among patients receiving OACs at all follow-up visits.
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