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January 1, 2015Circulation JournalOpen Access

Left Atrial Appendage Closure Reduces the Incidence of Postoperative Cerebrovascular Accident in Patients Undergoing Cardiac Surgery

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Key result

Left atrial appendage closure or amputation during cardiac surgery did not significantly reduce the overall incidence of postoperative cerebrovascular accidents compared to no closure (3.5% vs 3.0%, OR 1.07).

Why the study?

Does left atrial appendage surgical closure or amputation reduce the incidence of early postoperative cerebrovascular accident in patients undergoing cardiac surgery?

Population

1,831 consecutive patients undergoing cardiac surgery at a single center in Japan. Excluded patients with a…

Comparison

Left atrial appendage surgical closure or… vs No left atrial appendage closure or amputation…

Design

Cohort

Follow-up

up to 6 months

Authors

TKTomoko S. KatoKurume UniversityTITai IwamuraYokohama City University Medical CenterDEDaisuke EndoJuntendo University

Discussion

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Overview

LAA closure during surgery should not yet change practice; leaves open possible low CHA2DS2-VASc subgroup benefit for randomized confirmation.

Key Points

  • To determine whether surgical left atrial appendage closure or amputation reduces the incidence of postoperative cerebrovascular accidents within six months of cardiac surgery.
  • Conducted a prospective observational study of 1,831 consecutive patients (69.2% male, mean age 66.8±12.2 years) undergoing cardiac surgery between 2009 and 2013.
  • Evaluated 6-month postoperative cerebrovascular accident incidence in patients with (n=369, 20.2%) versus without left atrial appendage closure or amputation (LAAC/A), stratified by CHA2DS2-VASc stroke risk scores (<2 vs. ≥2).
  • Overall 6-month cerebrovascular accident incidence did not differ significantly between the LAAC/A and non-LAAC/A groups (3.5% vs. 3.0%, P=0.612), despite the LAAC/A group having larger baseline left atrial diameter (45.4 vs. 41.1 mm, P<0.001) and higher rates of postoperative atrial fibrillation (49.3% vs. 39.1%, P<0.001).
  • Multivariate analysis demonstrated that LAAC/A independently reduced cerebrovascular accidents in patients with CHA2DS2-VASc scores <2 (odds ratio <10^-6, P=0.021), whereas no significant association was observed in high-risk patients with scores ≥2.

Study Design

Type

Observational (n=1,831)

Multicenter

No

Structured PICO

Does left atrial appendage surgical closure or amputation reduce the incidence of early postoperative cerebrovascular accident in patients undergoing cardiac surgery?

P
Population
1,831 consecutive patients (mean age 66.8 years, 30.8% female) undergoing cardiac surgery, followed for up to 6 months to assess postoperative cerebrovascular accidents.
E
Exposure
Left atrial appendage surgical closure or amputation (LAAC/A) performed during open-heart surgery
C
Comparator
No left atrial appendage closure or amputation during cardiac surgery
O
Outcome
Incidence of early postoperative cerebrovascular accident (CVA), defined as ischemic or hemorrhagic intracranial stroke and TIA, up to 6 months after surgeryhard clinical

Main Result

Odds Ratio: 1.07 (95% CI 0.54–1.97)

Absolute Event Rate: 3.5% vs 3%

p-value: p=0.844

Prophylactic surgical left atrial appendage closure during cardiac surgery may reduce early postoperative stroke risk specifically in patients with a low CHA2DS2-VASc score (<2).

Limitations

  • Selection bias due to the observational design and surgeon preference for the procedure
  • Inability to discriminate between perioperative and postoperative CVA due to the small number of events
  • Short follow-up period preventing classification of postoperative rhythm status
  • Lack of independent analysis for patients with and without cardiopulmonary bypass
  • Cardiogenic CVA may not always be related to thrombi located in the left atrial appendage
  • Selection bias due to surgeon preference and changing indications over time
  • Prospective observational design without randomization
  • No independent analysis of patients undergoing cardiac surgery with and without cardiopulmonary bypass

Cite This Study

Kato et al. (2015) conducted an observational in Patients undergoing cardiac surgery (n=1,831). Left atrial appendage closure or amputation vs. No left atrial appendage closure or amputation was evaluated on Incidence of postoperative cerebrovascular accident within 6 months (OR 1.07, 95% CI 0.54-1.97, p=0.844). Left atrial appendage closure or amputation during cardiac surgery did not significantly reduce the overall incidence of postoperative cerebrovascular accidents compared to no closure (3.5% vs 3.0%, OR 1.07).

synapsesocial.com/papers/6a79a04b14b028facf0de39chttps://doi.org/10.1253/circj.cj-15-0524

Topics

Women and heart disease
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1The Clinical Impact of Incomplete Left Atrial Appendage Closure With the Watchman Device in Patients With Atrial Fibrillation2012 · 547 citations
  2. 2Left Atrial Appendage2010 · 644 citations
  3. 3Left atrial appendage: structure, function, and role in thromboembolism1999 · 693 citations
  4. 4Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery2008 · 692 citations
  5. 5Stroke mechanism in patients with non‐valvular atrial fibrillation according to the CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>‐VASc scores2011 · 46 citations