Key result
Surgical LAA exclusion is not linked to reduced stroke, whereas oral anticoagulation shows ~81% lower risk.
Why the study?
It remains unclear if surgical left atrial appendage exclusion decreases stroke incidence or impacts anticoagulation use in patients with atrial fibrillation undergoing cardiac surgery.
Does surgical LAA exclusion reduce stroke incidence or alter subsequent anticoagulation use in patients with atrial fibrillation undergoing cardiac surgery?
Case-Control (n=124)
No
Does surgical LAA exclusion reduce stroke incidence or alter subsequent anticoagulation use in patients with atrial fibrillation undergoing cardiac surgery?
Absolute Event Rate: 90% vs 81%
p-value: p=0.156
Surgical LAA exclusion during cardiac surgery does not appear to reduce stroke risk or alter long-term anticoagulation use, highlighting the continued need for oral anticoagulation in high-risk AF patients.
Anticoagulation decisions should remain independent of surgical LAA exclusion; leaves open its additive stroke benefit in prospective trials.
BACKGROUND: Surgical exclusion of the left atrial appendage (LAA) can be performed at the time of cardiac operation as a potential modality to decrease cardioembolic risk attributable to atrial fibrillation (AF), but it remains unclear if this decreases stroke incidence. Furthermore, it is not known whether LAA exclusion impacts the decision to discontinue anticoagulation impacting subsequent stroke risk. HYPOTHESIS: LAA exclusion does not significantly alter subsequent anticoagulation use or stroke incidence. METHODS: We studied 124 patients from Olmsted County with prior history of AF who underwent cardiac surgery at our institution between 1993 and 2015. Patients were divided into two groups on the basis of LAA exclusion and matched (1:1) according to 16 pretreatment variables using propensity scores obtained from a logistic regression model. Outcome data collected through chart review for survival, stroke, and the presence and duration of anticoagulation were compared between groups. RESULTS: The proportion of patients receiving anticoagulation at discharge and at 5 years was not significantly different between patients who underwent LAA exclusion and those who did not; 90% vs 81%, P = 0.156, 48% vs 49%, P = 0.722, respectively. On Kaplan-Meier analysis there were no significant differences in time free from stroke between cases and controls. Patients discharged on oral anticoagulation (OAC) had significantly lower risk of stroke (HR = 0.19, 95% confidence interval [CI] = 0.06-0.59, P = 0.004), independent of whether LAA closure was used. CONCLUSION: LAA exclusion did not appear to reduce early or late stroke. Only OAC was associated with a reduction in stroke risk, underscoring the need for continued anticoagulation in high-risk patients.
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Johnsrud et al. (2018) conducted a case-control in Atrial fibrillation (n=124). Surgical left atrial appendage (LAA) exclusion vs. No LAA exclusion was evaluated on Anticoagulation use at discharge (p=0.156). Surgical left atrial appendage exclusion did not alter anticoagulation use at discharge (90% vs 81%, P=0.156) or reduce stroke, whereas oral anticoagulation lowered stroke risk (HR 0.19; P=0.004).
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