Response by Mahmood et al to Letter Regarding Article, “Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery”

HomeCirculationVol. 142, No. 25Response by Mahmood et al to Letter Regarding Article, "Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBResponse by Mahmood et al to Letter Regarding Article, "Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery" Eitezaz Mahmood, MD, Aidan Sharkey, MD, Robina Matyal, MD, Feroze Mahmood, MD, Omar Chaudhary, MD and Kamal Khabbaz, MD Eitezaz MahmoodEitezaz Mahmood Department of Internal Medicine, North Shore University Hospital, Manhesset, NY (E.M.). , Aidan SharkeyAidan Sharkey Department of Anesthesia Critical Care and Pain Management (A.S., R.M., F.M., O.C.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. , Robina MatyalRobina Matyal Department of Anesthesia Critical Care and Pain Management (A.S., R.M., F.M., O.C.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. , Feroze MahmoodFeroze Mahmood Department of Anesthesia Critical Care and Pain Management (A.S., R.M., F.M., O.C.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. , Omar ChaudharyOmar Chaudhary Department of Anesthesia Critical Care and Pain Management (A.S., R.M., F.M., O.C.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. and Kamal KhabbazKamal Khabbaz Division of Cardiac Surgery (K.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Originally published21 Dec 2020https://doi.org/10.1161/CIRCULATIONAHA.120.051365Circulation. 2020;142:e504–e505In Response:We appreciate the letter from Dr Côté et al in response to our recently published article describing the effect of left atrial appendage (LAA) exclusion on short-term outcomes in isolated coronary artery bypass graft surgery.1 As alluded to by Dr Côté et al, our retrospective study is one of several in the literature assessing the effect of LAA ligation on patient outcomes within the short-term postoperative period. The results of our study are comparable to those of other large retrospective studies that have demonstrated an increased incidence of postoperative complications, including in-hospital deaths, in patients who underwent LAA ligation as part of their surgical procedure. However, because of the inherent limitations of retrospective evaluation, including inconsistencies in follow-up strategies, differing postsurgical medical regimens, and disparate LAA closure techniques, a definitive recommendation cannot be drawn from these studies.Although the finding of decreased levels of ANP (atrial natriuretic peptide) measured in patients who have undergone LAA ligation suggests that there is physiological plausibility to account for the increased incidence of postoperative heart failure in this particular subset of patients, a direct cause-and-effect relationship between LAA ligation and postoperative heart failure cannot be unequivocally established. Therefore, we await the results of LAAOS III (Left Atrial Appendage Occlusion Study III) by Dr Côté et al, which may offer more definitive data on the effect of concomitant LAA occlusion on thromboembolic outcomes and clarify whether LAA occlusion is in fact associated with a higher rate of 30-day readmission as demonstrated in our study.2 If the results of the LAAOS III study do reveal a trend toward an increase in early readmission in patients who have undergone LAA ligation, then further research is clearly warranted to obviate this effect.Possible treatment strategies to prevent acute heart failure exacerbations after LAA ligation may include more aggressive management of fluid overload in the early postoperative period with diuretic medications or the introduction of recombinant formulations of endogenous ANP. Augmenting natriuretic peptides and counteracting the renin-angiotensin-aldosterone system is an attractive target for the treatment of heart failure that has shown benefit in limited trials.3 Although treatment with designer natriuretic peptides remains in its infancy, it may be beneficial for those patients undergoing LAA ligation with respect to avoiding acute heart failure exacerbations.Needless to say, to reach a more conclusive recommendation on the usefulness of and, more important, the possible postoperative risks associated with LAA ligation at the time of cardiac surgery, more exact robust data are required from well-powered prospective randomized trials. The results of the LAAOS III study by Côté et al are eagerly awaited and will help inform our decision making with respect to this intervention.2DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circReferences1. Mahmood E, Matyal R, Mahmood F, Xu X, Sharkey A, Chaudhary O, Karani S, Khabbaz K. Impact of left atrial appendage exclusion on short-term outcomes in isolated coronary artery bypass graft surgery.Circulation. 2020; 142:20–28. doi: 10.1161/CIRCULATIONAHA.119.044642LinkGoogle Scholar2. Whitlock R, Healey J, Vincent J, Brady K, Teoh K, Royse A, Shah P, Guo Y, Alings M, Folkeringa RJ, et al.. Rationale and design of the Left Atrial Appendage Occlusion Study (LAAOS) III.Ann Cardiothorac Surg. 2014; 3:45–54. doi: 10.3978/j.issn.2225-319X.2013.12.06MedlineGoogle Scholar3. Hata N, Seino Y, Tsutamoto T, Hiramitsu S, Kaneko N, Yoshikawa T, Yokoyama H, Tanaka K, Mizuno K, Nejima J, et al.. Effects of carperitide on the long-term prognosis of patients with acute decompensated chronic heart failure: the PROTECT multicenter randomized controlled study.Circ J. 2008; 72:1787–1793. doi: 10.1253/circj.cj-08-0130CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails December 22, 2020Vol 142, Issue 25Article InformationMetrics Download: 472 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.051365PMID: 33347330 Originally publishedDecember 21, 2020 PDF download Advertisement SubjectsAtrial FibrillationCerebrovascular Disease/StrokeMyocardial Infarction