September 11, 2024Circulation Cardiovascular Interventions

Stroke Prevention With Prophylactic Left Atrial Appendage Occlusion in Cardiac Surgery Patients Without Atrial Fibrillation: A Meta-Analysis of Randomized and Propensity-Score Studies

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Why the study?

The role of left atrial appendage occlusion in patients without previous AF undergoing cardiac surgery is not established.

Does prophylactic left atrial appendage occlusion reduce the incidence of cerebrovascular accidents in patients without previous atrial fibrillation undergoing cardiac surgery?

Structured PICO

Does prophylactic left atrial appendage occlusion reduce the incidence of cerebrovascular accidents in patients without previous atrial fibrillation undergoing cardiac surgery?

Population

6 studies (randomized and propensity-score) pooling 4,130 patients with normal sinus rhythm (without previous atrial fibrillation) undergoing cardiac surgery.

Intervention

Prophylactic left atrial appendage occlusion (LAAO) concomitant with cardiac surgery

Comparator

Cardiac surgery without concomitant left atrial appendage occlusion

Outcome

Incidence of cerebrovascular accidents (CVAs)hard clinical

Prophylactic left atrial appendage occlusion during cardiac surgery in patients without prior atrial fibrillation is associated with a reduced risk of stroke and improved mid-term survival.

Implication

May reduce long-term CVA risk in sinus-rhythm surgical patients; leaves open need for randomized trials before practice change.

Abstract

BACKGROUND: The role of left atrial appendage occlusion (LAAO) in patients without previous atrial fibrillation (AF) is not established. This meta-analysis was conducted on patients with normal sinus rhythm who underwent cardiac surgery, with and without concomitant LAAO, to evaluate its effect on the incidence of cerebrovascular accidents (CVAs). METHODS: A systematic review was conducted from inception until December 2023 for randomized and propensity-score studies comparing CVA in patients without AF undergoing cardiac surgery with or without LAAO. RESULTS: Six studies met our inclusion criteria with a total of 4130 patients: 2146 in the LAAO group and 1984 in the no-LAAO group. The risk ratio of postoperative AF was 1.05 (95% CI, 0.86–1.28); P =0.628. The CVA rates at 5 years were 6.8±1.0% in the no-LAAO group and 4.3±0.8% in the LAAO group (log-rank P =0.021). The Cox regression analysis for CVA in patients undergoing LAAO reported a hazard ratio of 0.65 (95% CI, 0.45–0.94); P =0.022. Landmark analysis at 4 years highlighted a significant difference in overall survival between no-LAAO and LAAO groups, 86±12.2% versus 89.6±11.0%; P =0.041. CONCLUSIONS: In this meta-analysis of patients without previous AF undergoing cardiac surgery, LAAO was associated with a decreased risk of CVA, no difference in the incidence of postoperative atrial fibrillation, and a significant overall survival benefit at a 4-year landmark analysis. Although these findings support LAAO, the randomized LeAAPS trial (Left Atrial Appendage Exclusion for Prophylactic Stroke Reduction Trial), LAA-CLOSURE trial (A Randomized Prospective Multicenter Trial for Stroke Prevention by Prophylactic Surgical Closure of the Left Atrial Appendage in Patients Undergoing Bioprosthetic Aortic Valve Surgery), and LAACS-2 trial (Left Atrial Appendage Closure by Surgery-2) will help define the effectiveness of LAAO in patients undergoing cardiac surgery who have risk factors for AF and CVA. REGISTRATION: URL: https://www.crd.york.ac.uk/prospero/ ; Unique identifier: CRD42024496366.