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Mitsis A, Eftychiou C, Samaras A, Tzikas A, Fragakis N, Kassimis G. Left atrial appendage occlusion in atrial fibrillation: shaping the future of stroke prevention. Future Cardiol 2025; 21:391-404. [PMID: 40136040 PMCID: PMC12026124 DOI: 10.1080/14796678.2025.2484964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Accepted: 03/24/2025] [Indexed: 03/27/2025] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia, significantly increasing the risk of thromboembolic events, particularly ischemic stroke. The left atrial appendage (LAA) is the predominant site of thrombus formation in patients with AF, making it a crucial target for stroke prevention strategies. Left atrial appendage occlusion (LAAO) has emerged as an important therapeutic alternative to oral anticoagulation, particularly in patients with contraindications to long-term anticoagulant therapy. This review examines the role of LAAO in AF management, discussing current indications, patient selection, procedural techniques, and clinical outcomes. We also explore the latest evidence from major clinical trials and real-world studies, highlighting the efficacy and safety of LAAO compared to standard anticoagulation. Additionally, we consider the unresolved questions and the potential future directions for this intervention, including emerging technologies and the integration of LAAO into broader AF management protocols. Our review underscores the growing importance of LAAO in reducing thromboembolic risk in AF patients, particularly those unable to tolerate traditional anticoagulation, and offers insights into the ongoing evolution of this treatment modality in clinical practice.
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Affiliation(s)
- Andreas Mitsis
- Cardiology Department, Nicosia General Hospital, State Health Services Organization, Nicosia, Cyprus
| | - Christos Eftychiou
- Cardiology Department, Nicosia General Hospital, State Health Services Organization, Nicosia, Cyprus
| | - Athanasios Samaras
- Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Tzikas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Cardiology, European Interbalkan Medical Center, Thessaloniki, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Kassimis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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2
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Bhave PD, Dhaliwal KK, Chebrolu S, Brock J, Singleton MJ, Richardson KM. Clinical management after surgical left atrial appendage exclusion. J Cardiothorac Surg 2025; 20:153. [PMID: 40098197 PMCID: PMC11916981 DOI: 10.1186/s13019-025-03378-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 03/09/2025] [Indexed: 03/19/2025] Open
Abstract
BACKGROUND Surgical left atrial appendage (LAA) closure is an increasingly utilized approach to mitigate the risk of cardioembolic stroke in patients with atrial fibrillation (AF). Consensus is lacking regarding optimal stroke prevention management after surgical LAA management. OBJECTIVE To elucidate real world clinical management of anticoagulation in patients undergoing surgical LAA management. METHODS Over a 7-year period at a single center, 458 participants carried a diagnosis of AF and underwent surgical exclusion of their LAA during concomitant cardiac surgery. Follow-up was catalogued via retrospective chart review; median follow-up was 2 years. Successful LAA ligation was defined as maximal stump depth < 1.0 cm by transesophageal echocardiography (TEE) without distal leak. RESULTS Among 458 patients, 299 were discharged on OAC (142 DOAC and 157 warfarin). Of these, 31% (94/299) had a follow-up TEE. Among those without a TEE, 32% (65/205) were taken off OAC; among those who underwent TEE, 59% (55/94) were taken off OAC. Using a logistic regression model, there was no relationship between age, sex, CHA2DS2-VASc score, or creatinine and the probability of coming off of OAC. Among the 94 patients discharged on OAC who had a follow-up TEE:10 were unable to assess adequacy of closure, 69 were successful, and 15 showed unsuccessful closure. In the group with imaging confirmed successful exclusion of their LAA, 67% (46/69) were taken off their oral anticoagulation, with cessation occurring after the TEE in 93% (43/46) of those patients. CONCLUSION Clinical management after surgical LAA management, particularly with regard to LAA imaging and OAC continuation, is highly heterogeneous.
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Affiliation(s)
- Prashant D Bhave
- Department of Internal Medicine, Section on Cardiovascular Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, USA.
- Wake Forest Baptist Health, Department of Cardiology, 1 Medical Center Boulevard Winston-Salem, Winston-Salem, NC, 27157, USA.
| | | | - Sneha Chebrolu
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jonathan Brock
- Department of Internal Medicine, Section on Cardiovascular Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | | | - Karl M Richardson
- Department of Internal Medicine, Section on Cardiovascular Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
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Babapoor-Farrokhran S, Alzubi J, Port Z, Kaul R, Rasekhi RT, Farrokhran AB, Sooknanan N, Wiener PC, Khraisha O, Frishman WH, Mainigi SK, Aronow WS. Left Atrial Appendage Closure: What Do We Know? Cardiol Rev 2025; 33:153-159. [PMID: 37643211 DOI: 10.1097/crd.0000000000000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in the United States and the most common cause of embolic cerebrovascular events, with the majority of these thrombi originating in the left atrial appendage. The left atrial appendage (LAA) has separate developmental, ultrastructural, and physiological characteristics from the left atrium. Although LAA anatomy is highly variable, it can be categorized into 4 types: cactus, cauliflower, chicken wing, and windsock. The cauliflower type is associated with higher stroke risk in patients with nonvalvular AF. Although the cornerstone of therapy to prevent embolic strokes from AF has been anticoagulation with thrombin inhibitors, a large group of patients are unable to tolerate anticoagulation due to bleeding. This has led to the development and advancement of multiple surgical and percutaneous LAA closure devices to prevent embolic cerebrovascular accidents without the need for anticoagulation. In this article, we discuss the outcomes of major studies that utilized surgical LAA occlusion and its effectiveness. Furthermore, we summarize nonsurgical methods of LAA closure and future directions regarding LAA closure.
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Affiliation(s)
- Savalan Babapoor-Farrokhran
- From the Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY
| | - Jafar Alzubi
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Zachary Port
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Risheek Kaul
- From the Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY
| | | | | | - Naveen Sooknanan
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Philip C Wiener
- Department of Internal Medicine, Division of Cardiology, Washington University in St. Louis, St. Louis, MO
| | - Ola Khraisha
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Sumeet K Mainigi
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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Garg J, Kabra R, Gopinathannair R, Di Biase L, Wang DD, Saw J, Hahn R, Freeman JV, Ellis CR, Lakkireddy D. State of the Art in Left Atrial Appendage Occlusion. JACC Clin Electrophysiol 2025; 11:602-641. [PMID: 39797854 DOI: 10.1016/j.jacep.2024.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 10/21/2024] [Indexed: 01/13/2025]
Abstract
Left atrial appendage occlusion (LAAO) has become an important therapeutic target for stroke prevention in patients with nonvalvular atrial fibrillation. Over the past 2 decades, several advancements in LAAO devices (percutaneous and surgical) have been made for stroke prevention and arrhythmia therapy. However, there are several unanswered questions regarding optimal patient selection, the preferred LAAO approach and device, the management of periprocedural and postprocedural complications, including pericardial effusion, device-related thrombus, and device leaks. This review focuses on fundamental foundational concepts in various aspects of the left atrial appendage and management strategies as they relate to current clinical needs.
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Affiliation(s)
- Jalaj Garg
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Rajesh Kabra
- Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Kansas, USA
| | - Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Kansas, USA
| | - Luigi Di Biase
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Health, Detroit, Michigan, USA
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rebecca Hahn
- Department of Cardiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Christopher R Ellis
- Department of Medicine, Section of Cardiac Electrophysiology, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Kansas, USA.
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Sayed A, Kamal A, Kamal I, Fathallah AH, Nourelden AZ, Zaidi SA. Left Atrial Appendage Occlusion During Cardiac Surgery to Prevent Stroke: A Systematic Review and Meta-Analysis. Am J Cardiol 2025; 236:8-19. [PMID: 39477201 DOI: 10.1016/j.amjcard.2024.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 10/22/2024] [Accepted: 10/24/2024] [Indexed: 11/16/2024]
Abstract
Atrial fibrillation accounts for 1/6 of all strokes, potentially leading to significant disability and death. The left atrial appendage (LAA) is the primary location for thrombus formation. Excluding the LAA has been hypothesized to decrease the risk of ischemic stroke. This study examines LAA occlusion (LAAO) with otherwise indicated cardiac surgery and its effect on surgical outcomes. We followed the standards recommended by the Cochrane Collaborative Group and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to prepare this systematic review and meta-analysis. Studies were retrieved through an online bibliographic search, studies were screened, and data were extracted. We compared the 2 study arms (LAAO and cardiac surgery without LAAO). A total of 10 studies have been included in this study, and 6 randomized controlled trials were included in the meta-analysis, with data pooled from over 10,000 patients. LAAO is associated with no significant difference in the overall mortality (p = 0.98) and systemic embolism (p = 0.31). Strokes, particularly, ischemic strokes, have significantly lower risk in patients who underwent LAAO (p <0.0001 and p = 0.0007), respectively. In conclusion, LAAO can be done safely as a concomitant surgery with other cardiac surgeries, with a minimal incremental cost when performed concurrently. LAAO is associated with a lower risk of all stroke and ischemic strokes. Further studies are needed to shape guidance on the continuation versus discontinuation of anticoagulation after LAAO, especially in patient populations with a higher risk of bleeding.
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Affiliation(s)
- Alaa Sayed
- Department of Medicine, Mercy Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Abdallah Kamal
- Department of Medicine, Mercy Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Kamal
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | | | - Syed Arsalan Zaidi
- Department of Medicine, Mercy Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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6
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Rojas Sánchez PI. [Surgical closure of the left atrial appendage in cardiac surgery: a review article]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2024; 5:226-232. [PMID: 40391002 PMCID: PMC12087601 DOI: 10.47487/apcyccv.v5i4.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Accepted: 12/02/2024] [Indexed: 05/21/2025]
Abstract
Surgical occlusion of the left atrial appendage during cardiac surgery has been shown to significantly reduce the risk of stroke and systemic embolism in patients with atrial fibrillation and is currently a procedure with a high degree of recommendation. As cardiovascular surgeons we have the opportunity to offer this additional impactful surgical procedure, so the objective of this review is to understand its anatomical and surgical principles, in addition to evaluating the evidence that supports its indication.
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Affiliation(s)
- Pedro Iván Rojas Sánchez
- Hospital Nacional Alberto Sabogal Sologuren - EsSalud, Lima, Perú.Hospital Nacional Alberto Sabogal Sologuren - EsSaludLimaPerú
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Pyo WK, Kim JB, Cho YH, Je HG, Kim HJ, Lee SH. Long-term effects of left atrial appendage isolation in surgical ablation of atrial fibrillation based on lesion set: a multi-centre propensity-score weighted study. Open Heart 2024; 11:e002849. [PMID: 39353702 PMCID: PMC11448246 DOI: 10.1136/openhrt-2024-002849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 09/04/2024] [Indexed: 10/04/2024] Open
Abstract
BACKGROUND This present study aimed to investigate the impact of left atrial appendage (LAA) isolation on adverse clinical outcomes, with a further stratified analysis by biatrial (BA) and left atrial lesion sets, in patients with atrial fibrillation (AF) undergoing surgical ablation (SA) concurrent with mitral valve (MV) surgery. METHODS We evaluated 875 patients (aged 65.1±12.0 years) who underwent SA of AF concomitant to MV surgery, excluding those with mechanical prostheses requiring lifelong anticoagulation, between 2005 and 2017 in five tertiary cardiac centres in South Korea. Of these, 458 had isolated the LAA, whereas the remainder (n=417) had the LAA preserved. Comparative risk of stroke, mortality and AF recurrence was assessed between the groups, considering death as a competing event. Inverse-probability treatment weighting was used for baseline adjustment. RESULTS During the median follow-up of 57.4 months (IQR, 32.5-92.4 months), the adjusted risk of long-term stroke was significantly lower in the patients who underwent LAA isolation compared with those who preserved the LAA (subdistribution HR (SHR), 0.28; 95% CI 0.15 to 0.51; p<0.001). However, there were no significant differences in the adjusted risk of mortality (HR, 0.85; 95% CI 0.57 to 1.27; p=0.429) or AF recurrence (SHR, 0.92; 95% CI 0.78 to 1.08; p=0.291) between LAA isolation and preservation. In the subgroup of patients who underwent BA ablation, LAA isolation was associated with a lower long-term risk of stroke and AF recurrence (SHR, 0.77; 95% CI 0.61 to 0.94; p=0.029) compared with LAA preservation. CONCLUSIONS Concomitant LAA isolation during SA of AF in patients undergoing MV surgery was associated with a significantly lower risk of long-term stroke, but no survival benefit was observed.
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Affiliation(s)
- Won Kyung Pyo
- Department of Thoracic and Cariovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Seoul, Korea (the Republic of)
| | - Hyoung-Gon Je
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Hee Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University - Anam Campus, Seoul, Korea (the Republic of)
| | - Seung Hyun Lee
- Department of Thoracic and Cariovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
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Zhao Z, Yang C, Zhang W, He C, Ye G, Liu T, Ding C. Percutaneous or surgical LAAO for stroke prevention in patients with atrial fibrillation: A network meta-analysis. Heliyon 2024; 10:e37730. [PMID: 39323850 PMCID: PMC11421997 DOI: 10.1016/j.heliyon.2024.e37730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 08/30/2024] [Accepted: 09/09/2024] [Indexed: 09/27/2024] Open
Abstract
Background Stroke, which is mainly caused by thrombus formation in the left atrial appendage, represents the most prevalent complication of atrial fibrillation (AF). Both percutaneous left atrial appendage occlusion (p-LAAO) and surgical LAAO (s-LAAO) are used to treat AF and prevent stroke events. However, no head-to-head randomized controlled trials (RCTs) compared these strategies. Objective To examine the efficacy and safety of diverse strategies for reducing stroke risk using a network meta-analysis (NMA). Methods PubMed, EMBASE, and Cochrane repositories were explored to identify RCTs involving p-LAAO or s-LAAO, and five were included for NMA. This investigation adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses. The NMA was pooled using the Bayesian random effect framework. All findings were expressed as odds ratios accompanied by a 95 % confidence interval.The primary efficacy endpoint was any stroke (AS), and the secondary efficacy endpoint was combined AS and systematic embolism (AS/SE). The primary and secondary safety endpoints were major bleeding (MB) and all-cause death (ACD), respectively. Results Our meta-analysis incorporated 6337 individuals diagnosed with AF. The NMA demonstrated a reducing trend in AS and AS/SE for s-LAAO versus p-LAAO, while p-LAAO showed a benefit in reducing MB and ACD. Conclusions and Relevance: s-LAAO could potentially benefit individuals at elevated risk for stroke, whereas p-LAAO may be linked to a reduced likelihood of bleeding.
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Affiliation(s)
- Zihan Zhao
- Aerospace Center Hospital, China
- Peking University Aerospace School of Clinical Medicine, China
| | | | - Wenchang Zhang
- Aerospace Center Hospital, China
- Peking University Aerospace School of Clinical Medicine, China
| | - Changjian He
- Aerospace Center Hospital, China
- Peking University Aerospace School of Clinical Medicine, China
| | - Guojie Ye
- Aerospace Center Hospital, China
- Peking University Aerospace School of Clinical Medicine, China
| | - Tengfei Liu
- Aerospace Center Hospital, China
- Peking University Aerospace School of Clinical Medicine, China
| | - Chunhua Ding
- Aerospace Center Hospital, China
- Peking University Aerospace School of Clinical Medicine, China
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45:3314-3414. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Petersen J, Böning H, Yildirim S, Alassar Y, Yildirim Y, Bazhanov I, Sinning C, Reichenspurner H, Pecha S. Efficacy of four different left atrial appendage closure techniques during cardiac surgery-A transesophageal echocardiography follow-up study. JTCVS Tech 2024; 26:43-49. [PMID: 39156535 PMCID: PMC11329176 DOI: 10.1016/j.xjtc.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 08/20/2024] Open
Abstract
Objective Closure of the left atrial appendage (LAA) is a routine part of atrial fibrillation ablation surgery and significantly reduces stroke rates. Different LAA-closure techniques are used in cardiac surgery with variable results reported. We therefore evaluated the efficacy of 4 different LAA-closure techniques in patients undergoing cardiac surgery. Methods In total, 149 patients who underwent concomitant LAA closure during cardiac surgery between 2015 and 2019 were included in this retrospective transesophageal echocardiography study. Four different LAA-closure techniques were evaluated: LAA clipping (n = 62), suture ligation (n = 28), stapler resection (n = 30), and surgical LAA excision (n = 29). Successful LAA closure was defined as absence of LAA perfusion and absence of a stump greater than 10 mm. Results The mean patients age was 68.7 ± 9.4 years; 61.7% were male. No complications related to LAA closure were observed. Mean follow-up was 36.5 ± 8 months. Transesophageal echocardiography follow-up showed the following LAA closure success rates: LAA clip 98.4%, surgical excision 93.1%, stapler resection 76.6%, and suture ligation 39.2%. Suture ligation resulted in a high rate of recanalization (50%) and residual stumps (10.8%), whereas stapler resection resulted in a high rate of residual stumps (23.4%). Overall, 4 patients (2.7%) had a stroke during follow-up. In detail, 2 of 27 (7.4%) patients with unsuccessful LAA closure had a stroke, whereas 2 of the 122 (1.6%) patients with successful LAA closure had a stroke. Conclusions In our study, LAA clipping and surgical LAA excision proved to be both successful LAA-closure methods. External LAA ligation and stapler resection resulted in low rates of successful LAA closure and should be avoided.
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Affiliation(s)
- Johannes Petersen
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Henrike Böning
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Sevenai Yildirim
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Yousuf Alassar
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Yalin Yildirim
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Ilia Bazhanov
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Christoph Sinning
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Simon Pecha
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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11
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Święczkowski M, Dąbrowski EJ, Muszyński P, Pogorzelski P, Jemielita P, Dudzik JM, Januszko T, Duzinkiewicz M, Południewski M, Kuźma Ł, Kożuch M, Kralisz P, Dobrzycki S. A Comprehensive Review of Percutaneous and Surgical Left Atrial Appendage Occlusion. J Cardiovasc Dev Dis 2024; 11:234. [PMID: 39195142 DOI: 10.3390/jcdd11080234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/29/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide, and is associated with a significant risk of thromboembolic events. Left atrial appendage occlusion (LAAO) has emerged as a promising alternative for patients with contraindications or intolerance to anticoagulant therapy. This review summarises the current evidence, indications, and technical advancements in surgical and percutaneous LAAO. Preprocedural planning relies on various imaging techniques, each with unique advantages and limitations. The existing randomised clinical trials and meta-analyses demonstrate favourable results for both percutaneous and surgical LAAO. Postprocedural management emphasises personalised anticoagulation strategies and comprehensive imaging surveillance to ensure device stability and detect complications. Future focus should be put on antithrombotic regimens, investigating predictors of device-related complications, and simplifying procedural aspects to enhance patient outcomes. In summary, LAAO is presented as a valuable therapeutic option for preventing AF-related thromboembolic events, with ongoing research aimed at refining techniques and improving patient care.
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Affiliation(s)
- Michał Święczkowski
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Paweł Muszyński
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Piotr Pogorzelski
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Piotr Jemielita
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Joanna Maria Dudzik
- Second Department of Nephrology and Hypertension with Dialysis Unit, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Tomasz Januszko
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Małgorzata Duzinkiewicz
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Maciej Południewski
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Marcin Kożuch
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Paweł Kralisz
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Sławomir Dobrzycki
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
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12
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Chikwe J, Roach A, Emerson D, Chen Q, Rowe G, Gill G, Peiris A, Ramzy D, Cheng W, Egorova N, Trento A. Left atrial appendage closure during mitral repair in patients without atrial fibrillation. J Thorac Cardiovasc Surg 2024; 168:86-93.e5. [PMID: 37024010 PMCID: PMC11144458 DOI: 10.1016/j.jtcvs.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 02/02/2023] [Accepted: 02/19/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE Routine left atrial appendage closure during mitral repair in patients without atrial fibrillation (AF) is controversial. We aimed to compare the incidence of stroke after mitral repair in patients without recent AF according to left atrial appendage closure. METHODS An institutional registry identified 764 consecutive patients without recent AF, endocarditis, prior appendage closure, or stroke undergoing isolated robotic mitral repair between 2005 and 2020. Left atrial appendages were closed via left atriotomy using a double-layer continuous suture in 5.3% (15 out of 284) patients before 2014, versus 86.7% (416 out of 480) after 2014. The cumulative incidence of stroke (including transient ischemic attack) was determined using statewide hospital data. Median follow-up was 4.5 years (range, 0-16.6 years). RESULTS Patients undergoing left atrial appendage closure were older (63 vs 57.5 years, P < .001), with higher prevalence of remote AF requiring cryomaze (9%, n = 40 vs 1%, n = 3, P < .001). After appendage closure there were fewer reoperations for bleeding (0.7% [n = 3] vs 3% [n = 10]; P = .02), and more AF (31.8% [n = 137] vs 25.2% [n = 84]; P = .047). Two-year freedom from >2+ mitral regurgitation was 97%. Six strokes and 1 transient ischemic attack occurred after appendage closure compared with 14 and 5 in patients without (P = .002), associated with a significant difference in 8-year cumulative incidence of stroke/transient ischemic attack (hazard ratio, 0.3; 95% CI, 0.14-0.85; P = .02). This difference persisted in the sensitivity analysis, excluding patients undergoing concomitant cryomaze procedures. CONCLUSIONS Routine left atrial appendage closure during mitral repair in patients without recent AF appears safe and was associated with a lower risk of subsequent stroke/transient ischemic attack.
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Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif.
| | - Amy Roach
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Georgina Rowe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - George Gill
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Achille Peiris
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Danny Ramzy
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Wen Cheng
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Natalia Egorova
- Department of Population Health Science and Policy, Mount Sinai Medical Center, New York, NY
| | - Alfredo Trento
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
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13
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Maigrot JLA, Weiss AJ, Zhou G, Jenkins HN, Koroukian SM, Dewan KC, Soltesz EG. Outcomes After Left Atrial Appendage Clip Placement During Cardiac Surgery: A Nationwide Analysis. Am J Cardiol 2024; 220:39-46. [PMID: 38583697 DOI: 10.1016/j.amjcard.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/05/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024]
Abstract
This study evaluated the nationwide associations between concomitant left atrial appendage clip (LAAC) placement during cardiac surgery and postoperative outcomes. We identified 1,260,999 patients who underwent coronary artery bypass grafting, valve, and aortic surgeries in the 2016 to 2020 Nationwide Readmissions Database and stratified by concomitant LAAC versus no LAAC placement. Patients who underwent surgical ablation were excluded. Mortality and complications were compared during index admissions and for patients readmitted within 30 and 90 days of the index discharge date for unmatched and propensity score-matched groups. Overall, 6.7% (84,293) of patients underwent cardiac surgery and concomitant LAAC placement without surgical ablation. After propensity score matching, the index admission mortality and overall complications were not different in patients with LAAC versus patients without LAAC. LAAC placement was associated with increased any-cause 30-day readmissions (15% vs 13%, p <0.01). In patients with LAAC, within 30 days, there were no differences in mortality (3.9% vs 3.8%, p = 0.60) or overall complications (64% vs 63%, p = 0.20), whereas stroke was lower (5.3% vs 6.5%, p <0.01) and heart failure was higher (35% vs 30%, p <0.01). For patients readmitted within 90 days, similar findings were observed for any-cause readmissions, mortality, overall complications, stroke, and heart failure. In conclusion, concomitant LAAC placement during cardiac surgery was associated with lower early postdischarge incidence of stroke and a favorable overall risk-benefit profile. Given these short-term findings in a real-world population of all patients who underwent cardiac surgery, longer-term studies with more granular data are needed to evaluate the potential benefit of this practice.
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Affiliation(s)
- Jean-Luc A Maigrot
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aaron J Weiss
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Guangjin Zhou
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Haley N Jenkins
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Krish C Dewan
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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14
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Kowalewski M, Święczkowski M, Kuźma Ł, Maesen B, Dąbrowski EJ, Matteucci M, Batko J, Litwinowicz R, Kowalówka A, Wańha W, Jiritano F, Raffa GM, Malvindi PG, Pannone L, Meani P, Lorusso R, Whitlock R, La Meir M, de Asmundis C, Cox J, Suwalski P, Thoracic Research Centre. Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke. JTCVS OPEN 2024; 19:131-163. [PMID: 39015454 PMCID: PMC11247209 DOI: 10.1016/j.xjon.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/17/2023] [Accepted: 02/08/2024] [Indexed: 07/18/2024]
Abstract
Objective Left atrial appendage closure (LAAC) concomitant to heart surgery in patients with underlying atrial fibrillation (AF) has gained attention because of long-term reduction of thromboembolic complications. As of mortality benefits in the setting of non-AF, data from both observational studies and randomized controlled trials are conflicting. Methods On-line databases were screened for studies comparing LAAC versus no LAAC concomitant to other heart surgery. End points assessed were all-cause mortality and stroke at early and longest-available follow-up. Subgroup analyses stratified on preoperative AF were performed. Risk ratios (RR) with 95% CIs served as primary statistics. Results Electronic search yielded 25 studies (N = 660 [158 patients]). There was no difference between LAAC and no LAAC in terms of early mortality. In the overall population analysis, LAAC reduced long-term mortality (RR, 0.86; 95% CI, 0.74-1.00; P = .05; I 2 = 88%), reduced early stroke risk by 19% (RR, 0.81; 95% CI, 0.72-0.93; P = .002; I 2 = 57%), and reduced late stroke risk by 13% (RR, 0.87; 95% CI, 0.84-0.90; P < .001; I 2 = 58%). Subgroup analysis showed lower mortality (RR, 0.85; 95% CI, 0.72-1.01; P = .06; I 2 = 91%), short-, and long-term stroke risk reduction only in patients with preoperative AF (RR, 0.81; 95% CI, 0.71-0.93; P = .003; I 2 = 71% and RR, 0.87; 95% CI, 0.84-0.91; P < .001; I 2 = 70%, respectively). No benefit of LAAC in patients without AF was found. Conclusions Concomitant LAAC was associated with reduced stroke rates at early and long-term and possibly reduced all-cause mortality at the long-term follow-up but the benefits were limited to patients with preoperative AF. There is not enough evidence to support routine concomitant LAAC in non-AF settings.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Michał Święczkowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Łukasz Kuźma
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Bart Maesen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Jakub Batko
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Radosław Litwinowicz
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Adam Kowalówka
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
| | - Wojciech Wańha
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Federica Jiritano
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Paolo Meani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | | | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - James Cox
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
| | - Piotr Suwalski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Thoracic Research Centre
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
- Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
- Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
- McMaster University, Hamilton, Canada
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
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15
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Fong KY, Yeo S, Luo H, Kofidis T, Teoh KLK, Kang GS. Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg 2024; 94:522-535. [PMID: 38529814 DOI: 10.1111/ans.18947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/15/2023] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Selvie Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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16
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Je HG, Choi JW, Hwang HY, Kim HJ, Kim JB, Kim HJ, Choi JS, Jeong DS, Kwak JG, Park HK, Lee SH, Lim C, Lee JW. 2023 KASNet Guidelines on Atrial Fibrillation Surgery. J Chest Surg 2024; 57:1-24. [PMID: 37994091 DOI: 10.5090/jcs.23.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 11/24/2023] Open
Affiliation(s)
- Hyung Gon Je
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, Yangsan, Korea
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Jin Kim
- Departments of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Bum Kim
- Departments of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee-Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jae-Sung Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Han Ki Park
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Won Lee
- Department of Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
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17
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Elsheikh S, Hill A, Irving G, Lip GYH, Abdul-Rahim AH. Atrial fibrillation and stroke: State-of-the-art and future directions. Curr Probl Cardiol 2024; 49:102181. [PMID: 37913929 DOI: 10.1016/j.cpcardiol.2023.102181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/03/2023]
Abstract
Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.
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Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK.
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
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18
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Kowalewski M, Raffa GM, Pasierski M, Kołodziejczak M, Litwinowicz R, Wańha W, Wojakowski W, Rogowski J, Jasiński M, Widenka K, Hirnle T, Deja M, Bartus K, Lorusso R, Tobota Z, Maruszewski B, Suwalski P. Prognostic impact of preoperative atrial fibrillation in patients undergoing heart surgery in cardiogenic shock. Sci Rep 2023; 13:21818. [PMID: 38071378 PMCID: PMC10710503 DOI: 10.1038/s41598-023-47642-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/16/2023] [Indexed: 12/18/2023] Open
Abstract
Surgical intervention in the setting of cardiogenic shock (CS) is burdened with high mortality. Due to acute condition, detailed diagnoses and risk assessment is often precluded. Atrial fibrillation (AF) is a risk factor for perioperative complications and worse survival but little is known about AF patients operated in CS. Current analysis aimed to determine prognostic impact of preoperative AF in patients undergoing heart surgery in CS. We analyzed data from the Polish National Registry of Cardiac Surgery (KROK) Procedures. Between 2012 and 2021, 332,109 patients underwent cardiac surgery in 37 centers; 4852 (1.5%) patients presented with CS. Of those 624 (13%) patients had AF history. Cox proportional hazards models were used for computations. Propensity score (nearest neighbor) matching for the comparison of patients with and without AF was performed. Median follow-up was 4.6 years (max.10.0), mean age was 62 (± 15) years and 68% patients were men. Thirty-day mortality was 36% (1728 patients). The origin of CS included acute myocardial infarction (1751 patients, 36%), acute aortic dissection (1075 patients, 22%) and valvular dysfunction (610 patients, 13%). In an unadjusted analysis, patients with underlying AF had almost 20% higher mortality risk (HR 1.19, 95% CIs 1.06-1.34; P = 0.004). Propensity score matching returned 597 pairs with similar baseline characteristics; AF remained a significant prognostic factor for worse survival (HR 1.19, 95% CI 1.00-1.40; P = 0.045). Among patients with CS referred for cardiac surgery, history of AF was a significant risk factor for mortality. Role of concomitant AF ablation and/or left atrial appendage occlusion or more aggressive perioperative circulatory support should be addressed in the future.
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Affiliation(s)
- Mariusz Kowalewski
- Clinical Department of Cardiac Surgery and Transplantology, Centre of Postgraduate Medical Education, National Medical Institute of the Ministry of Interior and Administration, Wołoska 137 Str, 02-507, Warsaw, PL, Poland.
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy.
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland.
| | - Giuseppe M Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Michał Pasierski
- Clinical Department of Cardiac Surgery and Transplantology, Centre of Postgraduate Medical Education, National Medical Institute of the Ministry of Interior and Administration, Wołoska 137 Str, 02-507, Warsaw, PL, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Michalina Kołodziejczak
- Department of Anaesthesiology and Intensive Care, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Radosław Litwinowicz
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Jan Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Marek Jasiński
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Kazimierz Widenka
- Clinical Department of Cardiac Surgery, District Hospital No. 2, University of Rzeszów, Rzeszów, Poland
| | - Tomasz Hirnle
- Department of Cardiosurgery, Medical University of Bialystok, Bialystok, Poland
| | - Marek Deja
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
| | - Krzysztof Bartus
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Zdzisław Tobota
- Department of Pediatric Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan Maruszewski
- Department of Pediatric Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Suwalski
- Clinical Department of Cardiac Surgery and Transplantology, Centre of Postgraduate Medical Education, National Medical Institute of the Ministry of Interior and Administration, Wołoska 137 Str, 02-507, Warsaw, PL, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
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19
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Sulague RM, Whitham T, Danganan LML, Effiom V, Candelario K, Latif N, Hameed I. The Left Atrial Appendage and Atrial Fibrillation-A Contemporary Review. J Clin Med 2023; 12:6909. [PMID: 37959374 PMCID: PMC10650862 DOI: 10.3390/jcm12216909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
In patients with atrial fibrillation, the left atrial appendage may serve as the site of thrombus formation due to stasis that occurs within the appendage because of its shape and trabeculations. Although thrombus formation can be reduced by using anticoagulants, this may be contraindicated in some patients. The need for a better alternative treatment prompted the study of left atrial appendage occlusion for thromboembolism prophylaxis. Due to this, procedures that excise or occlude the left atrial appendage have gained attention because of their ability to prevent thromboembolic events. This article provides a comprehensive review of the left atrial appendage and its associated procedures' clinical utility.
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Affiliation(s)
- Ralf Martz Sulague
- Graduate School of Arts and Sciences, Georgetown University, Washington, DC 20057, USA;
| | - Tarik Whitham
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA;
| | | | - Victory Effiom
- College of Medical Sciences, University of Calabar, Calabar 540271, Nigeria;
| | - Katherine Candelario
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
| | - Nida Latif
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
| | - Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
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20
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Sylvester CB, Patel V, Ghanta RK, Loor G. Considerations for Left Atrial Appendage Occlusion During Cardiac Surgery. Cardiovasc Drugs Ther 2023; 37:1011-1019. [PMID: 36550349 DOI: 10.1007/s10557-022-07415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
Atrial fibrillation is associated with an increased risk of stroke secondary to thrombus formation in the left atrial appendage. Left atrial appendage occlusion (LAAO) is an effective method of reducing the risk of stroke in patients with atrial fibrillation. Although LAAO does not remove the requirement for anticoagulation, it reduces the risk of stroke when compared to anticoagulation alone. We critically analyze the data on LAAO in cardiac surgery. We also discuss the methods of LAAO, the risks of LAAO, and patient populations that could benefit from LAAO. We discuss high-level evidence that LAAO at the time of cardiac surgery reduces the risk of stroke in patients with a history of atrial fibrillation. In patients without a history of atrial fibrillation undergoing cardiac surgery, we suggest that LAAO should be considered in select patients at high risk of atrial fibrillation and stroke, when technically feasible.
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Affiliation(s)
- Christopher B Sylvester
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Vivek Patel
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Loor
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA.
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21
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Anduaga I, Affronti A, Cepas-Guillén P, Alcocer J, Flores-Umanzor E, Regueiro A, Brugaletta S, Quintana E, Sanchis L, Sabaté M, Freixa X. Non-Pharmacological Stroke Prevention in Atrial Fibrillation. J Clin Med 2023; 12:5524. [PMID: 37685589 PMCID: PMC10488500 DOI: 10.3390/jcm12175524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/11/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, and oral anticoagulation is nowadays the first-line treatment. However, since most thrombi form in the left atrial appendage and anticoagulant therapy may have side effects and be contraindicated in some patients, surgical and percutaneous left atrial appendage occlusion (LAAO) have emerged as a non-pharmacological alternative. This review summarizes all existing evidence on surgical and percutaneous LAAO.
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Affiliation(s)
- Iñigo Anduaga
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Alessandro Affronti
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Pedro Cepas-Guillén
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Jorge Alcocer
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Eduardo Flores-Umanzor
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Ander Regueiro
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Salvatore Brugaletta
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Eduard Quintana
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, 08007 Barcelona, Spain
| | - Laura Sanchis
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Manel Sabaté
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Xavier Freixa
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
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22
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Eqbal A, Tong W, Lamy A, Belley-Cote E, Paparella D, Bogachev-Prokophiev A, Royse AG, Reents W, Deveraux PJ, Brady K, Vincent J, Connolly SJ, Whitlock RP. Cost Implications of Left Atrial Appendage Occlusion During Cardiac Surgery: A Cost Analysis of the LAAOS III Trial. J Am Heart Assoc 2023; 12:e028716. [PMID: 37183832 PMCID: PMC10227308 DOI: 10.1161/jaha.122.028716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background The LAAOS III (Left Atrial Appendage Occlusion Study) clinical trial demonstrated that concomitant left atrial appendage (LAA) occlusion leads to a lower risk of ischemic stroke or systemic embolism compared with no occlusion in participants with atrial fibrillation and a CHA2DS2-VASc score of ≥2 undergoing cardiac surgery for another indication. We report the cost implications of concomitant LAA occlusion during cardiac surgery. Methods and Results Using LAAOS III data, we compared the costs (in US dollars) associated with LAA occlusion to no occlusion from the perspective of the Centers for Medicare and Medicaid Services. We calculated the average cost per participant during the trial by applying Medicare reimbursement costs to cardiovascular events for all trial participants. We conducted sensitivity analyses, varying the cost of stroke ±25% and occlusion technique use. Cost neutrality was defined as a mean cost difference within ±5% of the cost per participant in the no-occlusion group. Total study cost per participant was $3878 in the LAA occlusion group and $4490 in the no-occlusion group, a mean difference of -$612 (95% CI, -$1276 to $45). The main drivers of cost savings were fewer stroke events during the trial (mean difference of -$1021). In sensitivity analyses, LAA occlusion was cost saving for suture and stapler techniques but more expensive with closure device. Conclusions Concomitant LAA occlusion was cost saving for participants in LAAOS III. Our findings support concomitant LAA occlusion as an economically dominant strategy for patients with atrial fibrillation and a CHA2DS2-VASc score of ≥2 undergoing cardiac surgery.
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Affiliation(s)
- Adam Eqbal
- Division of Cardiac Surgery McMaster University Ontario Hamilton Canada
| | - Wesley Tong
- Population Health Research Institute McMaster University Ontario Hamilton Canada
| | - Andre Lamy
- Division of Cardiac Surgery McMaster University Ontario Hamilton Canada
- Population Health Research Institute McMaster University Ontario Hamilton Canada
| | - Emilie Belley-Cote
- Population Health Research Institute McMaster University Ontario Hamilton Canada
- Division of Cardiology McMaster University Ontario Hamilton Canada
| | - Domenico Paparella
- Division of Cardiac Surgery Santa Maria Hospital, Gruppo Villa Maria Care and Research Bari Italy
- Department of Medical and Surgical Science University of Foggia Foggia Italy
| | | | - Alistair G Royse
- Department of Surgery Royal Melbourne Hospital, The University of Melbourne Victoria Melbourne Australia
| | - Wilko Reents
- Rhön-Klinikum Campus Bad Neustadt Bad Neustadt Germany
| | - P J Deveraux
- Population Health Research Institute McMaster University Ontario Hamilton Canada
- Division of Cardiology McMaster University Ontario Hamilton Canada
| | - Katheryn Brady
- Population Health Research Institute McMaster University Ontario Hamilton Canada
| | - Jessica Vincent
- Population Health Research Institute McMaster University Ontario Hamilton Canada
| | - Stuart J Connolly
- Population Health Research Institute McMaster University Ontario Hamilton Canada
| | - Richard P Whitlock
- Division of Cardiac Surgery McMaster University Ontario Hamilton Canada
- Population Health Research Institute McMaster University Ontario Hamilton Canada
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23
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Kabra R, Gopinathannair R, Lakkireddy D. Left Atrial Appendage Occlusion During Cardiac Surgery: A 75-Year-Old Journey. J Am Heart Assoc 2023; 12:e030127. [PMID: 37183870 DOI: 10.1161/jaha.123.030127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Rajesh Kabra
- Kansas City Heart Rhythm Institute Overland Park KS USA
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24
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Rufa M, Göbel N, Franke UFW. Surgical atrial appendage closure: time for a randomized study. Herzschrittmacherther Elektrophysiol 2022; 33:386-390. [PMID: 36178509 DOI: 10.1007/s00399-022-00903-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and is assumed to affect more than 30 million people worldwide. Studies report that the left atrial appendage (LAA) plays an important role in thrombus formation and is considered the embolic source in 90% of affected patients with non-valvular and 57% with valvular AF. Oral anticoagulants have been the standard of care for stroke prevention in patients with AF for decades. However, bleeding complications and noncompliance are barriers to effective embolic protection. Therefore, as an alternative to conventional anti-thrombotic therapy, surgical LAA occlusion, which may lead to a reduced risk of thromboembolism, has received increasing attention. However, the procedure can be associated with additional risks such as prolonged operation time, damage to the circumflex coronary artery, and incomplete LAA occlusion. This review discusses some of the observational studies that have examined the impact of LAA occlusion on stroke, the LAAOS III (Left Atrial Appendage Occlusion Study) trial, which provided definitive evidence for the benefit of surgical LAA occlusion on ischemic stroke, which surgical methods are safe and effective for LAA occlusion, and whether oral anticoagulation can be stopped after surgical removal of the LAA.
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Affiliation(s)
- Magdalena Rufa
- Department of Cardiovascular Surgery, Robert Bosch Hospital Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany.
| | - Nora Göbel
- Department of Cardiovascular Surgery, Robert Bosch Hospital Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany
| | - Ulrich F W Franke
- Department of Cardiovascular Surgery, Robert Bosch Hospital Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany
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25
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Ye C, Han X, Chen Y, Xu D. Early myocardial injury and coagulation activation in thoracoscopic left atrial appendage clipping. J Card Surg 2022; 37:4919-4927. [PMID: 36378905 DOI: 10.1111/jocs.17169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Thoracoscopic left atrial appendage clipping as a new strategy for stroke prevention. This study was established to observe the changes in myocardial injury and coagulation during the perioperative to provide the basis for anticoagulation strategy. METHODS Fifty-two patients with nonvalvular atrial fibrillation who completed thoracoscopic left atrial appendage clipping alone and 52 matched controls with thoracoscopic lobectomy were included in the study. The changes in coagulation and myocardial enzyme during the perioperative period were compared by t-test or nonparametric test. Linear correlation analysis was performed on the trend changes of each indicator in the left atrial appendage clipping group. RESULTS Compared with the control group, the postoperative cardiac troponin I level in the thoracoscopic left atrial appendage clip group was significantly higher than that before the operation; there was no significant difference in the increase of myoglobin between the two groups. In the coagulation function, there was no significant difference in the increase of fibrinogen between the two groups. Postoperative D-dimer and fibrin degradation products were significantly increased, especially the left atrial appendage clip group was significantly higher than the control group, and even showed a trend of secondary increase. Cardiac troponin I was positively correlated with C-reactive protein, fibrinogen and von Willebrand Factor activity, and the Spearman nonparametric correlation coefficients were 1, 0.829, and 0.829, respectively (all p < .05). CONCLUSION Thoracoscopic left atrial appendage closure surgery presents early myocardial injury and activation of coagulation function. The secondary increase of coagulation index needs our attention.
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Affiliation(s)
- Cong Ye
- Department of Cardiac Surgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, Fengtai District, Beijing, China
| | - Xuesong Han
- Department of Cardiac Surgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, Fengtai District, Beijing, China
| | - Yiming Chen
- Department of Cardiac Surgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, Fengtai District, Beijing, China
| | - Dong Xu
- Department of Cardiac Surgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, Fengtai District, Beijing, China
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26
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Ascaso M, David CM, Fan CPS, Saha S, David TE. Closure of Left Atrial Appendage Has no Effect on Thromboembolic Rates after Mitral Valve Repair in Patients in Sinus Rhythm. Semin Thorac Cardiovasc Surg 2022; 36:150-157. [PMID: 36423865 DOI: 10.1053/j.semtcvs.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/23/2022]
Abstract
Closure of the left atrial appendage (LAA) reduces the rates of TIA/stroke in patients in atrial fibrillation (AF) but its role in patients in sinus rhythm who undergo mitral valve repair (MV) for leaflet prolapse remains unknown. This study examined the effects of closing the LAA in TIA/stroke after MV repair. Our database on patients who had MV repair for leaflet prolapse from 2000 through 2019 was reviewed. After excluding patients at higher risk of TIA/stroke, 1050 patients in sinus rhythm were entered into the study: 781 with open LAA and 269 with surgically closed LAA. Using a propensity score analysis to compensate from clinical differences, 267 pairs of patients with open and closed LAA were matched. Follow-up was truncated at 5 years because routine closure of the LAA was performed only during recent years. The cumulative incidence of TIA/stroke at 5 years in the entire cohort was 2.7% [95% CI 1.9, 4.0]; it was 2.9% [95% CI 1.9, 4.4] in patients with open LAA,and 1.8% [95% CI 0.7, 4.9] in patients with closed LAA (P = 0.53). In the matched cohorts, the cumulative incidences of TIA/stroke did not differ significantly (match-adjusted HR [95% CI] = 0.80 [0.21, 2.98], P = 0.74), and multivariable Cox proportional hazard regression analysis also confirmed no difference in the risk of TIA/stroke between the 2 groups (regression-adjusted HR [95% CI] = 0.58 [0.12, 2.9], P = 0.47). This study failed to show a reduction in the risk of TIA/stroke by closing the LAA in patients in sinus rhythm (Figure 6). Closure of the LAA during MV repair warrants a larger and more rigorous study.
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Affiliation(s)
- Maria Ascaso
- Division of Cardiovascular Surgery of University Health Network and Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Carolyn M David
- Division of Cardiovascular Surgery of University Health Network and Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Division of Cardiovascular Surgery of University Health Network and Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Sudipta Saha
- Division of Cardiovascular Surgery of University Health Network and Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Tirone E David
- Division of Cardiovascular Surgery of University Health Network and Peter Munk Cardiac Centre, Toronto, Ontario, Canada..
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27
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Ye C, Han X, Chen Y, Liu F, Ma H, Yang Y, Liu Y, Hu Q, Yao Q, Xie W, Xu D. Stroke prevention of thoracoscopic left atrial appendage clipping in patients with non-valvular atrial fibrillation at high risk of stroke and bleeding: study protocol for a non-randomised controlled clinical trial. BMJ Open 2022; 12:e063931. [PMID: 36307161 PMCID: PMC9621168 DOI: 10.1136/bmjopen-2022-063931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/04/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Non-valvular atrial fibrillation (NVAF) is a high-risk factor for ischaemic stroke. The 2016 European Society of Cardiology Atrial Fibrillation Management guidelines recommend oral anticoagulants (OACs) to prevent stroke in men with CHA2DS2-VASc scores ≥2 and women ≥3. However, in patients with a high risk of stroke and a high risk of bleeding (HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) score≥3), OAC had a higher risk of bleeding. Left atrial appendage closure (LAAC) is non-inferior to OAC as a means of preventing stroke in several studies. As a minimally invasive intervention to prevent stroke, transthoracic LAAC (TS-LAAC) has a high successful closure rate, but there is a lack of literature reports directly comparing it with OAC. Our research compares TS-LAAC with novel oral anticoagulants (NOACs) and provides an appropriate programme for stroke prevention in a specific population. METHODS AND ANALYSIS This is a non-randomised controlled trial study protocol, and we will conduct this study from April 2022 to April 2025. The study included 186 patients with confirmed NVAF, 93 of whom completed thoracoscopic LAAC, and the control group treated with NOACs. The primary outcome was the incidence of stroke and systemic embolism, as well as the composite endpoint events (stroke, systemic embolism, myocardial infarction, bleeding, cardiovascular death, etc). Secondary outcomes were ischaemic stroke, haemorrhagic stroke, any bleeding events, death from cardiovascular causes, death from all causes, residual root rate in the surgery group, device-related thrombosis in the surgery group, changes in blood pressure, cardiac chamber size changes, etc. Each subject completed at least 1 year of follow-up. ETHICS AND DISSEMINATION The study has been approved by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medical University, China (approval number: KY2022-013-02). The results from this study will be disseminated through manuscript publications and national/international conferences. TRIAL REGISTRATION NUMBER ChiCTR2200058109.
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Affiliation(s)
- Cong Ye
- Department of Cardiac Surgery, Capital Medical University, Beijing, China
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Xuesong Han
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yiming Chen
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Fei Liu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Hao Ma
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yu Yang
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yang Liu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Qingfeng Hu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Qing Yao
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Wenting Xie
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Dong Xu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
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Kowalewski M, Wańha W, Litwinowicz R, Kołodziejczak M, Pasierski M, Januszek R, Kuźma Ł, Grygier M, Lesiak M, Kapłon-Cieślicka A, Reczuch K, Gil R, Pawłowski T, Bartuś K, Dobrzycki S, Lorusso R, Bartuś S, Deja MA, Smolka G, Wojakowski W, Suwalski P. Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER): protocol for a prospective observational nationwide study. BMJ Open 2022; 12:e063990. [PMID: 36130748 PMCID: PMC9494590 DOI: 10.1136/bmjopen-2022-063990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a prevalent disease considerably contributing to the worldwide cardiovascular burden. For patients at high thromboembolic risk (CHA2DS2-VASc ≥3) and not suitable for chronic oral anticoagulation, owing to history of major bleeding or other contraindications, left atrial appendage occlusion (LAAO) is indicated for stroke prevention, as it lowers patient's ischaemic burden without augmentation in their anticoagulation profile. METHODS AND ANALYSIS Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER) will be conducted in 10 heart surgery and cardiology centres across Poland to assess the outcomes of LAAO performed by fully thoracoscopic-epicardial, percutaneous-endocardial or hybrid endo-epicardial approach. The registry will include patients with nonvalvular AF at a high risk of thromboembolic and bleeding complications (CHA2DS2-VASc Score ≥2 for males, ≥3 for females, HASBLED score ≥2) referred for LAAO. The first primary outcome is composite procedure-related complications, all-cause death or major bleeding at 12 months. The second primary outcome is a composite of ischaemic stroke or systemic embolism at 12 months. The third primary outcome is the device-specific success assessed by an independent core laboratory at 3-6 weeks. The quality of life (QoL) will be assessed as well based on the QoL EQ-5D-5L questionnaire. Medication and drug adherence will be assessed as well. ETHICS AND DISSEMINATION Before enrolment, a detailed explanation is provided by the investigator and patients are given time to make an informed decision. The patient's data will be protected according to the requirements of Polish law, General Data Protection Regulation (GDPR) and hospital Standard Operating Procedures. The study will be conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the local Bioethics Committee of the Upper-Silesian Medical Centre of the Silesian Medical University in Katowice (decision number KNW/0022/KB/284/19). The results will be published in peer-reviewed journals and presented during national and international conferences. TRIAL REGISTRATION NUMBER NCT05144958.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Radoslaw Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Michalina Kołodziejczak
- Department of Anaesthesiology and Intensive Care, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland
| | - Michal Pasierski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Rafal Januszek
- Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Marek Grygier
- Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Maciej Lesiak
- Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Krzysztof Reczuch
- Centre for Heart Disease, University Hospital Wroclaw Department of Heart Disease, Wroclaw Medical University, Wrocław, Poland
| | - Robert Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Tomasz Pawłowski
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Sławomir Dobrzycki
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stanislaw Bartuś
- Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Andrzej Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Grzegorz Smolka
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
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Nso N, Nassar M, Zirkiyeva M, Lakhdar S, Shaukat T, Guzman L, Alshamam M, Foster A, Bhangal R, Badejoko S, Lyonga Ngonge A, Tabot-Tabot M, Mbome Y, Rizzo V, Munira MS, Thambidorai S. Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis. IJC HEART & VASCULATURE 2022; 40:100998. [PMID: 35655531 PMCID: PMC9152299 DOI: 10.1016/j.ijcha.2022.100998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/21/2022] [Accepted: 03/07/2022] [Indexed: 01/13/2023]
Abstract
Surgical left atrial appendage occlusion (LAAO) is being used increasingly in the setting of atrial fibrillation but has been associated with procedural complications. This systematic review and meta-analysis compared the outcomes of surgical LAAO with those of no LAAO and the use of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) using the PRISMA guidelines. A literature search was undertaken for relevant studies published between January 1, 2003, and August 15, 2021. Primary clinical outcomes were all-cause mortality, embolic events, and stroke. Secondary clinical outcomes included major adverse cardiac events (MACE), postoperative atrial fibrillation, postoperative complications, reoperation for bleeding, and major bleeding. There was a statistically significant 34% reduction in incidence of embolic events (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.57-0.77, p < 0.001) and a significant 42% reduction in risk of MACE (OR 0.58, 95% CI 0.38-0.88, p = 0.01) in patients who underwent LAAO.Surgical LAAO has the potential to reduce embolic events and MACE in patients undergoing cardiac surgery for atrial fibrillation. However, complete replacement of DOACs and warfarin therapy with surgical LAAO is unlikely despite its non-inferiority in terms of minimizing all-cause mortality, embolic events, MACE, major bleeding, and stroke in patients on oral anticoagulation therapies.
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Key Words
- AF, atrial fibrillation
- All-cause mortality
- Atrial fibrillation
- CI, confidence interval
- DOACs, direct oral anticoagulants
- Direct oral anticoagulants
- LA, left atrium
- LAA, left atrial appendage
- LAAO, left atrial appendage occlusion
- Left atrial appendage occlusion
- MACE, major adverse cardiac events
- NOACs, novel oral anticoagulants
- OR, odds ratio
- Stroke
- VKAs, vitamin K antagonists
- Vitamin K antagonists
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Affiliation(s)
- Nso Nso
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Mahmoud Nassar
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Milana Zirkiyeva
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Sofia Lakhdar
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Tanveer Shaukat
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Laura Guzman
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Mohsen Alshamam
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Allison Foster
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Rubal Bhangal
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Solomon Badejoko
- Department of Medicine, St. Joseph’s Medical Center, Stockton, CA, USA
| | | | - Mpey Tabot-Tabot
- Department of Medicine, Howard University Hospital, Washington, DC, USA
| | - Yolanda Mbome
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Vincent Rizzo
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Most S. Munira
- Division of Cardiovascular Disease, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Senthil Thambidorai
- Chief of Cardiovascular Medicine Division, HCA Medical City of Fort Worth, TX/ Assistant Professor of Medicine -TCU and UNTHSc School of Medicine, Fort Worth, TX, USA
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Whitlock RP, Belley-Côté EP. Concomitant Surgical Left Atrial Appendage Occlusion: a Review. Curr Cardiol Rep 2022; 24:823-828. [PMID: 35488947 DOI: 10.1007/s11886-022-01705-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss some of the observational studies that examined the impact of left atrial appendage occlusion on stroke, the Left Atrial Appendage Occlusion Study (LAAOS) III research program that provided definitive evidence for the benefit of surgical left atrial appendage occlusion on ischemic stroke, and high priority studies in the field that should be pursued by the surgical community. RECENT FINDINGS Atrial fibrillation is common in patients undergoing cardiac surgery. Oral anticoagulants are effective at preventing strokes related to atrial fibrillation; they have been the standard of care for stroke prevention in patients with atrial fibrillation for decades. Most strokes in patients with atrial fibrillation originate from the left atrial appendage. LAAOS III, a large randomized controlled trial, has recently demonstrated that concomitant left atrial appendage occlusion in patients undergoing cardiac surgery for another indication reduces the risk of stroke or systemic embolism on top of oral anticoagulation. Surgical left atrial appendage occlusion reduces the risk of ischemic stroke and systemic embolism in patients with atrial fibrillation and a CHA2DS2-VASc score ≥ 2 undergoing cardiac surgery for another indication. The role of surgical left atrial appendage occlusion with patients without atrial fibrillation, as a substitute to anticoagulation and as a standalone procedure, remains unclear.
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Affiliation(s)
- Richard P Whitlock
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada. .,Population Health Research Institute, 237 Barton Street E, Hamilton, ON, L8L 2X2, Canada.
| | - Emilie P Belley-Côté
- Population Health Research Institute, 237 Barton Street E, Hamilton, ON, L8L 2X2, Canada.,Divisions of Cardiology and Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
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31
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Fatima R, Dhingra NK, Ribeiro R, Bisleri G, Yanagawa B. Routine left atrial appendage occlusion in patients undergoing cardiac surgery: a narrative review. Curr Opin Cardiol 2022; 37:165-172. [PMID: 34723850 DOI: 10.1097/hco.0000000000000925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW New evidence suggests a greater prevalence of protracted postoperative atrial fibrillation (POAF) than previously recognized. The left atrial appendage (LAA) is the most common source of embolism in patients with nonvalvular atrial fibrillation. In this review, we ask whether there is evidence to support routine LAA occlusion (LAAO) in patients without preexisting atrial fibrillation undergoing cardiac surgery. RECENT FINDINGS Overall, available studies are small, inconsistent and have varying proportions of patients with and without preexisting atrial fibrillation. There is considerable discrepancy with respect to the efficacy of LAAO in reducing the risk of POAF-related stroke. Only one study reported a lower rate of stroke in the LAAO group compared with no LAAO. Two studies included a subgroup analysis of patients that developed POAF and report a significantly higher rate of stroke in patients that developed POAF and did not undergo LAAO. There are three clinical trials ongoing that are investigating prophylactic LAAO in patients undergoing cardiac surgery: ATLAS, LAA-CLOSURE and LAACS-2. SUMMARY There is currently insufficient evidence to recommend routine addition of LAAO to lower the risk of postoperative stroke. Ongoing clinical trials will provide important insight into the role of routine LAAO in all patients undergoing cardiac surgery.
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Affiliation(s)
- Rubab Fatima
- Kingston General Hospital, Queen's University, Kingston
| | - Nitish K Dhingra
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roberto Ribeiro
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Prasad RM, Saleh Y, Al-Abcha A, Abdelkarim O, Abdelfattah OM, Abdelnabi M, Almaghraby A, Elwany M, DeBruyn E, Abela GS. Left atrial appendage closure during cardiac surgery for atrial fibrillation: A meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:26-36. [PMID: 34801420 DOI: 10.1016/j.carrev.2021.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) during cardiac surgery in atrial fibrillation (AF) patients has been investigated in multiple studies with variable safety and efficacy results. METHODS A comprehensive review was performed of all studies comparing LAAC and placebo arm during cardiac surgery in AF patients. A random-effect model was used to calculate risk ratios, mean differences, and 95% confidence intervals. RESULTS Five randomized controlled trials and 22 observational studies were included with a total of 540,111 patients. The LAAC group had significantly decreased postoperative stroke/embolic events as compared to the no LAAC group with all cardiac surgeries (3.74% vs 4.88%, p = 0.0002), isolated valvular surgery (1.95% vs 4.48%, p = 0.002). However, CABG insignificantly favored the LAAC group for stroke/embolic events (6.72% vs 8.30%, p = 0.07). There was no difference between both groups in all-cause mortality in the perioperative period (p = 0.42), but was significantly lower in the LAAC arm after two years (14.1% vs 18.3%, p = 0.02). There was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time between both groups (p = 0.53 and p = 0.45). The bypass and the cross-clamp time were longer in the LAAC group (4 and 9 min, respectively). CONCLUSION In AF patients, LAAC during cardiac surgery had a decreased risk of stroke and long-term all-cause mortality. Additionally, there was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time.
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Affiliation(s)
- Rohan Madhu Prasad
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA.
| | - Yehia Saleh
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA; Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Abdullah Al-Abcha
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - Ola Abdelkarim
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA; Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Omar M Abdelfattah
- Department of Internal Medicine, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA
| | - Mahmoud Abdelnabi
- Internal Medicine Department, Texas Tech University Health Science Center, Lubbock, Texas, USA
| | | | - Mostafa Elwany
- Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Elise DeBruyn
- College of Medicine, University of Illinois, Chicago, IL, USA
| | - George S Abela
- Department of Cardiology, Michigan State University, East Lansing, MI, USA
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Collado FMS, Lama von Buchwald CM, Anderson CK, Madan N, Suradi HS, Huang HD, Jneid H, Kavinsky CJ. Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2021; 10:e022274. [PMID: 34668395 PMCID: PMC8751840 DOI: 10.1161/jaha.121.022274] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.
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Mohamed MMG, Faisaluddin M, Kheiri B, Osman M. Meta-analysis of Surgical Left Atrial Appendage Occlusion During Cardiac Surgery. Am J Cardiol 2021; 155:150-151. [PMID: 34315567 DOI: 10.1016/j.amjcard.2021.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Mohamed M G Mohamed
- Internal Medicine Department, SSM Health St. Mary's Hospital, St. Louis Missouri
| | | | - Babikir Kheiri
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
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35
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Concomitant left atrial appendage occlusion in patients undergoing cardiac surgery. Indian J Thorac Cardiovasc Surg 2021; 37:605-607. [PMID: 34511776 DOI: 10.1007/s12055-021-01236-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022] Open
Abstract
The Left Atrial Appendage Occlusion Study (LAAOS III) was a multicenter, randomized controlled trial that included patients undergoing cardiac surgery who also had atrial fibrillation. The trial recruited 4811 participants, of which 2400 patients were randomized to undergo left atrial appendage (LAA) occlusion surgery, while 2411 participants had isolated cardiac surgery. The aim of the study was to determine whether concomitant occlusion of the LAA prevents ischemic stroke or systemic embolism. The study also evaluated the efficacy and safety of concomitant LAA occlusion in patients undergoing cardiac surgery. The number of ischemic strokes or systemic embolisms was significantly lower in the LAA occlusion group [114 (4.8%) vs. 68 (7.0%)] compared to the no-occlusion surgery group. There was also no increase in hospital length of stay or hospitalization for heart failure. It is expected that based on the findings of the LAAOS III study, the recommendations for concomitant LAA occlusion will be upgraded from the current class IIB to class I.
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36
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Ren J, Yang Y, Zhu J, Wu S, Wang J, Zhang H, Shao X. The Characteristics, Long-Term Outcomes, Risk Factors, and Antithrombotic Therapy in Chinese Patients With Atrial Fibrillation and Bioprosthetic Valves. Front Cardiovasc Med 2021; 8:665124. [PMID: 34179131 PMCID: PMC8222517 DOI: 10.3389/fcvm.2021.665124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/07/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction: There were few data about the clinical profiles and long-term outcomes in Chinese patients with atrial fibrillation (AF) and bioprosthetic valves. Methods: The retrospective study enrolled 903 patients with bioprosthetic valve replacement at our hospital and discharged with a diagnosis of AF from January 2010 to December 2018. Results: The median age was 65.6 (61.9–69.1) years, and 548 (60.7%) patients were women. During a follow-up period of 3.84 (2.64–5.51) years, 68 (1.8 per 100 person-years) patients died, 81 (2.1 per 100 person-years) patients developed thromboembolism, and 23 (0.6 per 100 person-years) patients experienced major bleeding. The CHA2DS2-VASc score, as a categorical variable (low, moderate, or high risk), predicted the risk of thromboembolism with the C-statistic of 0.6 (95% CI: 0.511–0.689, p = 0.046). The incidence of the CHA2DS2-VASc score increment was 11.6 per 100 person-years, and the annual reclassification rate of stroke risk (from a low or moderate group to a higher group) was 12.7%. The current proportion of oral anticoagulants was 52.3, 59, and 63.2%, respectively, in the low, moderate, and high stroke risk groups. Age (OR: 1.04, 95% CI: 1.01–1.06, p = 0.01), left atrial size (OR: 1.05, 95% CI: 1.03–1.08, p < 0.001), and rheumatic heart disease (OR: 1.49, 95% CI: 1.05–2.10, p = 0.025) were positively associated with the use of oral anticoagulants. The history of chronic kidney disease (OR: 0.20, 95% CI: 0.05–0.76, p = 0.018), prior surgical ablation (OR: 0.33, 95% CI: 0.24–0.47, p < 0.001), and antiplatelet agent use (OR: 0.08, 95% CI: 0.05–0.13, p < 0.001) were inversely related to the use of oral anticoagulants. Higher admission estimated glomerular filtration rate (HR: 0.515, 95% CI: 0.311–0.853, p = 0.01), left ventricular ejection fraction (HR: 0.961, 95% CI: 0.931–0.992, p = 0.014), concomitant surgical ablation (HR: 0.348, 95% CI: 0.171–0.711, p = 0.004), and rheumatic heart disease history (HR: 0.515, 95% CI: 0.311–0.853, p = 0.01) were associated with a lower risk of death. Surgical ablation (HR: 0.263, 95% CI: 0.133–0.519, p < 0.001) and oral anticoagulants (HR: 0.587, 95% CI: 0.375–0.918, p = 0.019) were related to a lower risk of thromboembolism. Conclusion: Chinese patients with AF and bioprosthetic valve(s) were relatively young and had a high prevalence of rheumatic heart disease with few comorbidities. The percentage of mitral bioprosthetic valve replacement was high. The proportion of concomitant surgical ablation or surgical left atrial appendage occlusion or exclusion was relatively low. The thromboembolic events were the major long-term adverse events. The anticoagulation therapy was underused in patients at moderate or high stroke risk. The CHA2DS2-VASc score was verified to be used for predicting stroke risk in this population. The stroke risk dynamically changed; it needed to be reestimated once the risk factor changed.
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Affiliation(s)
- Jiameng Ren
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanmin Yang
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhu
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Wu
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juan Wang
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han Zhang
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinghui Shao
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Freedman B, Hindricks G, Banerjee A, Baranchuk A, Ching CK, Du X, Fitzsimons D, Healey JS, Ikeda T, Lobban TCA, Mbakwem A, Narasimhan C, Neubeck L, Noseworthy P, Philbin DM, Pinto FJ, Rwebembera J, Schnabel RB, Svendsen JH, Aguinaga L, Arbelo E, Böhm M, Farhan HA, Hobbs FDR, Martínez-Rubio A, Militello C, Naik N, Noubiap JJ, Perel P, Piñeiro DJ, Ribeiro AL, Stepinska J. World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update. Glob Heart 2021; 16:41. [PMID: 34211827 PMCID: PMC8162289 DOI: 10.5334/gh.1023] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023] Open
Abstract
The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.
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Affiliation(s)
- Ben Freedman
- Heart Research Institute, University of Sydney, Sydney, AU
| | | | | | | | | | - Xin Du
- Beijing Anzhen Hospital, Capital Medical University, CN
| | | | | | | | - Trudie C. A. Lobban
- Arrhythmia Alliance & Atrial Fibrillation Association, Stratford Upon Avon, UK
| | - Amam Mbakwem
- Lagos University Teaching Hospital, Idi Araba, Lagos, NG
| | | | | | | | | | - Fausto J. Pinto
- Santa Maria University Hospital (CHULN), CAML, CCUL, Lisboa, PT
| | | | | | | | | | - Elena Arbelo
- Hospital Clinic de Barcelona, Universitat de Barcelona, ES
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Hornburg/Saar, DE
| | | | | | | | | | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi, IN
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Jang SJ, Wong SC, Mosadegh B. Leaks after Left Atrial Appendage Closure: Ignored or Neglected? Cardiology 2021; 146:384-391. [PMID: 33735867 DOI: 10.1159/000513901] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/12/2020] [Indexed: 11/19/2022]
Abstract
Left atrial appendage (LAA) closure has recently been approved as an alternative management for stroke prevention in patients with chronic atrial fibrillation who have difficulties with long-term oral anticoagulation. The various shapes and sizes of LAA and orientation of the atrial ostium may contribute to the incomplete LAA closure from circular design devices and orientation of the non-steerable delivery catheter. Incomplete closure of LAA leads to a high-velocity blood flow through the peri-device gap, resulting in peri-device leak (PDL). Residual leaks are frequently diagnosed after LAA closure procedures, regardless of closure methods. There is a controversy in the clinical significance of the leaks, particularly about its association with thromboembolic events. PDL <5 mm was not associated with any increase of risk for thromboembolism. Current literatures with small study population have not been sufficient to clarify the role of the leaks after LAA closure. Nevertheless, management of severe leaks has been a challenging concern for cardiologists. Leaks after epicardial LAA closures are at the neck of the incompletely closed LAA and have shown to increase the risk of thromboembolism. Percutaneous closure of the leaks after LAA closure has been attempted with good safety and success, but long-term safety and efficacy remains unclear. Further large long-term studies which aim to assess the role of leaks or PDLs in predicting thromboembolic events and management strategies are warranted.
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Affiliation(s)
- Sun-Joo Jang
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA
| | - S Chiu Wong
- Greenberg Cardiology Division, Weill Cornell Medicine, New York, New York, USA
| | - Bobak Mosadegh
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA,
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Rashid HN, Layland J. Modification of the left atrial appendage and its role in stroke risk reduction with non-valvular atrial fibrillation. IJC HEART & VASCULATURE 2021; 32:100688. [PMID: 33354620 PMCID: PMC7744943 DOI: 10.1016/j.ijcha.2020.100688] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/21/2020] [Accepted: 11/27/2020] [Indexed: 12/30/2022]
Abstract
Atrial fibrillation is one of the most common cardiovascular disorders encountered by clinicians in clinical practice. Patients with atrial fibrillation are at risk of cerebrovascular and systemic embolic events, which may be attenuated by commencement of anticoagulation therapy. Even so, due to extremely high bleeding risk certain patients may not be suitable for long-term anticoagulation therapy. The left atrial appendage is a common site for thrombus formation in patients with atrial fibrillation. Left atrial appendage exclusion, either surgical or percutaneous, has been performed to ostensibly reduce the risk of cerebrovascular events and potentially minimise or omit anticoagulation therapy in select patients. This review summarises the role of the left atrial appendage in cerebrovascular events, current evidence with modification of the left atrial appendage and future trials that may change practice with these procedures.
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Key Words
- ACC, American College of Cardiology
- AF, Atrial fibrillation
- AHA, American Heart Association
- Atrial fibrillation
- DRT, Device related thrombus
- ESC, European Society of Cardiology
- FDA, Food and Drug Administation
- HR, Hazard ratio
- LAA, Left atrial appendage
- LAAE, Left atrial appendage exclusion
- LGE, Late gadolinium enhancement
- Left atrial appendage occluder
- Left atrial appendage occlusion
- OAC, Oral anticoagulation
- OR, Odds ratio
- Stroke
- TOE, Trans-oesopheageal echocardiogram
- Thrombosis
- Watchman device
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Affiliation(s)
- Hashrul N. Rashid
- Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia
- Department of Cardiovascular Research, Peninsula Health, Melbourne, Australia
| | - Jamie Layland
- Department of Cardiovascular Research, Peninsula Health, Melbourne, Australia
- Peninsula Clinical School, Monash University, Melbourne, Australia
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41
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 6318] [Impact Index Per Article: 1579.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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42
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Chow JY, McClure G, Belley-Côté EP, McIntyre WF, Singal RK, Whitlock RP. Costs of surgical ablation of atrial fibrillation in Ontario, Canada from 2006 to 2017. J Card Surg 2020; 35:3451-3454. [PMID: 32985724 DOI: 10.1111/jocs.14989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/10/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND International guidelines currently recommend concomitant surgical ablation of atrial fibrillation (AF) in patients with AF undergoing cardiac surgery. However, a systematic review and meta-analysis of 23 randomized controlled trials (RCTs) showed no significant difference in mortality or stroke in patients who underwent surgical AF ablation compared with those who did not (moderate-quality evidence). METHODS We estimated the Ontario-wide costs of surgical AF ablation between 2006 and 2017 using data from a systematic review and meta-analysis of RCTs, estimates of case volumes from Ontario Health Insurance Plan fee codes, the ongoing left atrial appendage occlusion study III trial (NCT01561651), institutional costs from large academic centers in Ontario, as well as professional fees based on the Ontario fee schedule. Device costs were obtained from Canadian industry data with expert input. RESULTS We estimated the average extra cost of surgical AF ablation at $4,287 CAD (95% CI $4,113-4,619) per patient. Procedural costs (equipment costs and physician remuneration) comprise 82.2% of this, while smaller portions relate to the increased need for pacemaker (3.9%) and additional hospital length of stay (13.9%). Approximately 2,391 patients underwent surgical AF ablation between 2006 and 2017, corresponding to an estimated $10.2 million in incremental cost during that time span. CONCLUSION Ontario taxpayers spend significant financial resources on surgical ablation of AF, a procedure lacking high-quality evidence demonstrating benefit in reducing mortality or stroke. Further large prospective studies examining clinically important outcomes are needed to justify its routine use in patient care and to guide allocation of healthcare funds.
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Affiliation(s)
- Justin Y Chow
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Graham McClure
- Division of Vascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada
| | - William F McIntyre
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Rohit K Singal
- CVT Associates, Vancouver Island Health Authority, Victoria, British Columbia, Canada
| | - Richard P Whitlock
- Population Health Research Institute, Hamilton, Ontario, Canada.,Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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43
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Masroor S, Glower DB. The time may soon be at hand. J Card Surg 2020; 35:3403-3404. [PMID: 32985710 DOI: 10.1111/jocs.15019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Saqib Masroor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Donald B Glower
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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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. [PMID: 32489114 DOI: 10.1161/circulationaha.119.044642] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the impact of left atrial appendage (LAA) exclusion on short-term outcomes in patients with atrial fibrillation undergoing isolated coronary artery bypass graft surgery. METHODS We queried the 2010 to 2014 National Readmissions Database for patients who underwent coronary artery bypass graft repair with and without LAA ligation by using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification: 36.1xx). Only patients with a history of atrial fibrillation were included in our analysis. The primary outcome of our study was 30-day readmissions following discharge. Secondary outcomes were in-hospital mortality and stroke. To assess the postoperative outcomes, we used multivariate logistic regression models to adjust for clinical and demographic covariates. RESULTS In total, we analyzed 253 287 patients undergoing coronary artery bypass graft surgery, 7.0% of whom received LAA closure. LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P<0.0001) and acute kidney injury (21.8% versus 18.5%, P<0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with a nonsignificant reduction in stroke (7.9% versus 8.6%, P=0.12), no difference in in-hospital mortality (2.2% versus 2.2% P=0.99), and a greater risk of 30-day readmission (16.0% versus 9.6%, P<0.0001). After covariate adjustment, LAA ligation remained a significant predictor of 30-day readmission (odds ratio, 1.640 [95% CI, 1.603-1.677], P<0.0001). CONCLUSIONS LAA exclusion during isolated coronary artery bypass graft surgery in patients with atrial fibrillation is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.
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Affiliation(s)
- Eitezaz Mahmood
- Departments of Cardiothoracic Surgery (E.M., K.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Internal Medicine, North Shore University Hospital, Manhasset, NY (E.M.)
| | - Robina Matyal
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Xinling Xu
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aidan Sharkey
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Omar Chaudhary
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sadia Karani
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kamal Khabbaz
- Departments of Cardiothoracic Surgery (E.M., K.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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45
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Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation: a national cohort study. J Interv Card Electrophysiol 2020; 57:399-407. [PMID: 30712076 PMCID: PMC9903467 DOI: 10.1007/s10840-019-00519-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO. METHODS In a nationally-representative, contemporary cohort (07/2011-06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models. RESULTS In this cohort (average age, 76 years; 39% female), 4177 (37%) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25% ("unprotected" patients). The overall propensity for S-LAAO decreased significantly with increasing CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (ptrend < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers. CONCLUSIONS Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA2DS2-VASc score-defined stroke risk).
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46
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Edgerton JR. Current State of Surgical Left Atrial Appendage Exclusion: How and When. Card Electrophysiol Clin 2020; 12:109-115. [PMID: 32067640 DOI: 10.1016/j.ccep.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Left atrial appendage exclusion is efficacious for stroke prophylaxis in patients with atrial fibrillation. Surgical excision provides reliable left atrial appendage exclusion, whereas surgical occlusion does not. Specifically, 2-layer internal suture ligation has a high failure rate. Left atrial appendage exclusion concomitant to another cardiac surgical procedure is indicated in patients with atrial fibrillation but not in patients without baseline atrial fibrillation. Studies currently underway will further define the role of concomitant surgical left atrial appendage exclusion, especially for the population without baseline atrial fibrillation but at high risk of developing postoperative atrial fibrillation.
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Affiliation(s)
- James R Edgerton
- Department of Epidemiology, Baylor Scott and White Health, PO Box 190667, Dallas, TX 75219, USA.
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47
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Martín Gutiérrez E, Castaño M, Gualis J, Martínez-Comendador JM, Maiorano P, Castillo L, Laguna G. Beneficial effect of left atrial appendage closure during cardiac surgery: a meta-analysis of 280 585 patients. Eur J Cardiothorac Surg 2019; 57:252-262. [DOI: 10.1093/ejcts/ezz289] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 12/30/2022] Open
Abstract
Abstract
In non-rheumatic atrial fibrillation (AF), left atrial appendage (LAA) is thought to be the source of embolism in 90% of the strokes. Thus, as recent clinical trials have shown the non-inferiority of percutaneous LAA closure (LAAc) in comparison to medical treatment, and despite a IIb recommendation in the latest guidelines for concomitant surgical LAAc, we sought to investigate the beneficial effect of LAAc in the surgical population. A meta-analysis model was performed comparing studies including any cardiac surgery with or without concomitant surgical LAAc reporting stoke/embolic events and/or mortality, from inception to January 2019. Twenty-two studies (280 585 patients) were included in the model. Stroke/embolic events both in the perioperative period [relative risk (RR) 0.66, 95% confidence interval (CI) 0.53–0.82; P = 0.0001] and during follow-up of >2 years (RR 0.67, 95% CI 0.51–0.89; P < 0.005) were significantly reduced in patients who underwent surgical LAAc (RR 0.71, 95% CI 0.58–0.87; P = 0.001). Regarding the rate of preoperative AF, LAAc showed protective effect against stroke/embolic events in studies with >70% preoperative AF (RR 0.64, 95% CI 0.53–0.77; P < 0.00001) but no benefit in the studies with <30% of preoperative AF (RR 0.77, 95% CI 0.46–1.28; P = 0.31). Postoperative mortality was also significantly lower in surgical patients with LAAc at the mid- and long-term follow-up. (RR 0.72, 95% CI 0.67–0.78; P < 0.00001; I2 = 0%). Based on these findings, concomitant surgical LAAc is associated with lower rates of embolic events and stroke in the postoperative period in patients with preoperative AF and also improves postoperative mortality in the mid- and long-term follow-up.
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Affiliation(s)
| | - Mario Castaño
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
| | - Javier Gualis
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
| | | | - Pasquale Maiorano
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
| | - Laura Castillo
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
| | - Gregorio Laguna
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
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48
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Ibrahim AM, Tandan N, Koester C, Al-Akchar M, Bhandari B, Botchway A, Abdelkarim J, Maini R, Labedi M. Meta-Analysis Evaluating Outcomes of Surgical Left Atrial Appendage Occlusion During Cardiac Surgery. Am J Cardiol 2019; 124:1218-1225. [PMID: 31474327 DOI: 10.1016/j.amjcard.2019.07.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 12/13/2022]
Abstract
Surgical left atrial appendage occlusion (S-LAAO) has become a common procedure performed in patients undergoing cardiac surgery; however, evidence to support this procedure remains inconclusive. This meta-analysis aims to assess the efficacy of S-LAAO in terms of ischemic stroke, postoperative atrial fibrillation, and all-cause mortality. A thorough literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We identified 10 relevant studies for our meta-analysis. It included 6,779 patients who underwent S-LAAO and 6,573 who did not undergo LAAO. In terms of ischemic stroke, the S-LAAO cohort had a lower events (pooled odds ratio [OR] 0.655 (0.518 to 0.829), p = 0.0004) compared with the non-LAAO cohort. S-LAAO cohort also had lower events of all-cause mortality (pooled OR 0.74 (95% confidence interval 0.55 to 0.99), p = 0.0408) when compared with the non-LAAO cohort. In regards to postoperative atrial fibrillation, there was no difference between the 2 groups (pooled OR 1.29 (95% confidence interval 0.81 to 2.06), p = 0.2752). In conclusion, S-LAAO was associated with lower events of ischemic stroke or systemic embolism and all-cause mortality when compared to the non-LAAO group.
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Affiliation(s)
- Abdisamad M Ibrahim
- Department of Internal Medicine, SIU School of Medicine, Springfield, Illinois.
| | - Nitin Tandan
- Department of Internal Medicine, SIU School of Medicine, Springfield, Illinois
| | - Cameron Koester
- Department of Internal Medicine, SIU School of Medicine, Springfield, Illinois
| | - Mohammad Al-Akchar
- Department of Internal Medicine, SIU School of Medicine, Springfield, Illinois
| | - Bishal Bhandari
- Department of Internal Medicine, SIU School of Medicine, Springfield, Illinois
| | - Albert Botchway
- Center for Clinical Research, SIU School of Medicine, Springfield, Illinois
| | - Jumana Abdelkarim
- Department of Internal Medicine, SIU School of Medicine, Springfield, Illinois
| | - Ruby Maini
- Department of Internal Medicine, SIU School of Medicine, Springfield, Illinois
| | - Mohamed Labedi
- Division of Cardiology, Department of Internal Medicine, SIU School of Medicine, Springfield, Illinois
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Karim N, Ho SY, Nicol E, Li W, Zemrak F, Markides V, Reddy V, Wong T. The left atrial appendage in humans: structure, physiology, and pathogenesis. Europace 2019; 22:5-18. [DOI: 10.1093/europace/euz212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/12/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
For many years, the left atrial appendage (LAA) was considered a dormant embryological remnant; however, it is a structurally complex and functional organ that contributes to cardiac haemodynamic changes and volume homeostasis through both its contractile properties and neurohormonal peptide secretion. When dysfunctional, the LAA contributes to thrombogenesis and subsequent increased predisposition to cardioembolic events. Consequently, the LAA has gained much attention as a therapeutic target to lower this risk. In addition, attention has focused on the LAA in its role as an electrical trigger for atrial tachycardia and atrial fibrillation with ablation of the LAA to achieve electrical isolation showing promising results in the maintenance of sinus rhythm. This in-depth review explores the structure, physiology and pathophysiology of the LAA, as well as LAA intervention and their sequelae.
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Affiliation(s)
- Nabeela Karim
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Siew Yen Ho
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Edward Nicol
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Wei Li
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Filip Zemrak
- Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
| | - Vias Markides
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Vivek Reddy
- Helmsley Centre for Cardiac Electrophysiology, Mount Sinai Hospital, New York City, NY, USA
| | - Tom Wong
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
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50
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Left Atrial Appendage Electrical Isolation as a Target in Atrial Fibrillation. JACC Clin Electrophysiol 2019; 5:407-416. [DOI: 10.1016/j.jacep.2019.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/21/2022]
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