Evaluation of anticoagulation use and subsequent stroke in patients with atrial fibrillation after empiric surgical left atrial appendage closure: A retrospective case‐control study

Abstract

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.

Left atrial appendage exclusion is effective in reducing postoperative stroke after mitral valve replacement

“…A similar pattern in patients' characteristics between the LAA exclusion and nonexclusion groups in the AF subgroup to the total population was seen ( This study showed that exclusion of LAA by closing it using a double-layer suture during MVR reduced the incidence of ischemic stroke during hospitalization, particulary in patients with AF. It is consistent with several other observational studies [8][9][10][11][12][13][14][15] where LAA exclusion has been recognized as a protective factor for different types of patients undergoing cardiac surgery ( Table 5).…”

Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke

“…PRISMA flow diagram presenting the study selection process is available in Figure 1 . Electronic search returned 25 studies (N = 660 [158 patients]) 8 , 9 , 10 , 11 , 12 , 13 , 15 , 18 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , E1 , E9 to be included in the systematic review. Seven studies were RCTs 10 , 15 , 18 , 33 , 34 , E3 , E4 ; of the remaining, 8 9 , 12 , 29 , 32 , 35 , E2 , E7 provided adjusted estimates.…”

“…The prevalence of AF varied across studies and ranged from 0% 15 to 100%. 8 , 10 , 11 , 13 , 28 , 29 , 30 , 31 , 35 , E2 , E4 , E5 , E7 Yao and colleagues 9 provide outcome data for patients with AF and those without separately. In studies labeled as predominantly AF, 99.7% of patients had preoperative AF.…”

Surgical left atrial appendage occlusion in patients with atrial fibrillation undergoing mechanical heart valve replacement

“…[ 11 ] However, a recent study from the Mayo Clinic [ 14 ] using a propensity-matched analysis did not demonstrate that SLAAO significantly influenced the risk of stroke or long-term mortality. Furthermore, Johnsrud et al , [ 15 ] also from the Mayo Clinic, published a PSM analysis and stated that SLAAO did not appear to reduce the incidence of early or late stroke.…”