ACCEL
Effectiveness of Left Atrial Appendage Occlusion Among Atrial Fibrillation Patients Undergoing Cardiac Surgery: A Report from the Society of Thoracic Surgeons Adult Cardiac Surgery Database
September 01, 2017.Daniel J Friedman, MD, Durham, NC
Educational Objectives
After completing the activity, the clinician will be better able to describe evidence relating to the use of simultaneous left atrial appendage occlusion in older patients with atrial fibrillation undergoing a first-time cardiac surgery.
Summary
Interviewer: Allan S. Jaffe, MD, FACC
Take-home Messages:
- In a nationally representative cohort of patients with atrial fibrillation (AF) who were undergoing cardiac surgery (usually valve or bypass surgery), simultaneous left atrial appendage occlusion (LAAO) was associated with lower rates of thromboembolism (TE) and all-cause mortality.
- The lower risk of TE occurred predominantly among patients discharged from the hospital without anticoagulation.
- Although randomized trial data are needed, the evidence supports adding LAAO to patients with AF undergoing cardiac surgery
During heart surgery on older patients with atrial fibrillation, new data suggest it might be wise to consider closing off the left atrial appendage (LAA) while you’re there.
The LAA is implicated as the site of thrombus formation in up to 90% of TE events among patients with nonrheumatic AF. Sure, systemic oral anticoagulation reduces the risk of TEs, but only about one-half of all eligible patients take these medications. The LAA can be surgically occluded at the time of cardiac surgery, but until now there has been only limited data supporting the effectiveness of this procedure.
Thus, Friedman and colleagues decided to perform a large (n = 10,524) comparative effectiveness analysis in a contemporary, nationally representative cohort of individuals with AF or atrial flutter. They used the Society of Thoracic Surgeons National Database to identify Medicare recipients with AF undergoing first-time cardiac surgery.
Patients were predominantly male (61%), had a median age of 76, and were at high risk for stroke (median CHA2DS2-VASc score of 4; interquartile range: 3 to 5). The primary surgery for the group was well divided between mitral valve (30%), aortic valve (35%), and isolated coronary artery bypass graft (CABG) surgery (35%). (Mitral and aortic valve procedures could be performed with or without CABG.) Of the overall population studied, 37% underwent LAAO at the time of cardiac surgery.
These patients tended to be in better cardiovascular health than those who did not undergo surgical LAAO. Nevertheless, after multivariate analysis, the surgical LAAO procedure was associated with a 40% reduction in TE at 1 year (the primary endpoint: rehospitalization for ischemic stroke, transient ischemic attack, or systemic embolism), a 15% reduction in all-cause death (a secondary endpoint), and a reduction in the combined endpoint of TE, hemorrhagic stroke, or death, all statistically significant at 1 year compared to cardiac surgery without LAAO (Table). The lower risk of TE occurred predominantly among patients who were discharged from the hospital without blood thinners.
Daniel J. Friedman, MD, a cardiology research fellow at the Duke Clinical Research Institute (DCRI), Durham, North Carolina, presented the data at the 2017 American College of Cardiology meeting. “Our study suggests that surgical left atrial appendage occlusion appears safe regardless of whether patients received anticoagulation therapy after discharge, and it could be particularly beneficial for patients who cannot take anticoagulation therapies for medical reasons,” he said. As of now, he said, it is an approach that should be considered for patients similar to the population studied.
Comparative Effectiveness of LAAO Among Patients with AF Undergoing Concomitant Cardiac Surgery
| LAAO | No LAAO | Unadjusted HR | Adjusted HR | |
| Thromboembolism | 1.6% | 2.5% | 0.63 | 0.62 |
| All-cause mortality | 7.0% | 10.8% | 0.63 | 0.85 |
| Hemorrhagic stroke | 0.2% | 0.3% | 0.70 | 0.64 |
| TE, hemorrhagic stroke, or death | 8.7% | 13.5% | 0.63 | 0.70 |
AF = atrial fibrillation; hr = hazard ratio; LAAO = left atrial appendage occlusion; TE = thromboembolism.
The study’s principal investigator, J. Matthew Brennan, MD, also of DCRI, added, “Patients scheduled to undergo open-heart surgery should talk with their surgical teams about closure of the left atrial appendage. Particularly among patients with atrial fibrillation, this may be one of the most effective available treatments to prevent future strokes. Until randomized trials are available, this study will represent the strongest available data in this field.”
Readings
Disclosures
Daniel J Friedman, MD
Boston Scientific Corp (O); St. Jude Medical Inc (O)
Interviewer: Allan S. Jaffe, MD, FACC
Abbott (C); Alere (C); Beckman Coluter Inc (C); ET Healthcare Inc (C); NeuroGenomeX Inc (C); Novartis AG (C); F. Hoffman-LaRoche Ltd (C); Siemens Corp (C); sphingotec GmbH (C)
Acknowledgements
CME/CE INFO
Accreditation:
The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.
Lecture ID:
AC490910
Expiration:
This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.
Instructions:
To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.
Estimated time to complete this CME/CE course:
Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.
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