Do Patients With Atrial Fibrillation Being At High-risk For Stroke Benefit From Concomitant Left Atrial Appendix Closure During Cardiac Surgery?
Tomas Kozmik1, Julia Pisarenko2, Wilko Weissenberger1, Fanar Mourad1, Sharaf Shehada1, Daniel Wendt1, Konstantinos Tsagakis1, Omar Abou Issa1, Ilir Balaj1, Mohammed El-Gabry1, Heinz Jakob1, Markus Neuhäuser2, Matthias Thielmann1.
1West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany, 2Department of Mathematics and Technique, Koblenz University of Applied Science, Remagen, Germany.
BACKGROUND-Left atrial appendix (LAA), as an essential source of systemic embolism and stroke in patients with atrial fibrillation, can be excluded during cardiac surgery (CS), however the clinical benefit is as yet uncertain.METHODS—A total of 376 out of 3741 consecutive patients with atrial fibrillation presenting a high risk for stroke (CHA2DS2-VASc-Score ≥2) who underwent CS between 01/2012 and 12/2015 were analysed for mortality and stroke rate at 30 days, 12 and 24 months. Patients with concomitant LAA-closure alone(group1;n=107) were compared to patients with concomitant surgical ablation and LAA-closure (group2;n=85), and patients without surgical ablation and no LAA-closure (group3;n=184) as controls. To further adjust for pre- and intraoperative risk factors, a propensity score stratification analysis based on patients age, gender, EuroSCORE-2, CHA2DS2-VASc-Score and type of procedure was performed.RESULTS—Patients age was 72±8 years (mean±SD) and 33% were female. EuroSCORE-2 was 8.7±7.7%, 5.7±3.9%, and 5.4±8.4% and CHA2DS2-VASc-Score was 4.2±1.5, 3.9±1.4, and 4.1±1.4 on average for the respective groups. Mortality did not differ between groups at 30 days, 12 and 24 months. The incidence of stroke was 1.9% at 30 days, 4.8% at 12 and 6.7 % at 24 months in group1. There was no stroke at 30 days and 12 months but 1.3% at 24 months in group2, and 1.8% at 30days, 3.0% at 12 and 24 months in control group3. The overall mortality at 24 months was 27.1%, 20% and 24.6% respectively. After propensity score adjustment, stroke rate showed significant benefit in group 2 (P=0.005) at 12 months and a hazard ratio of 0.17, 95% confidents limits 0.02-1.50, (P=0.08) at 24 months, whereas overall mortality did not significantly differ between the groups at 12 and 24 months follow-up. CONCLUSIONS—In this propensity score risk-adjusted analysis, patients undergoing CS with surgical ablation and concomitant LAA-closure had significant fewer strokes at 12 months follow-up compared to patients undergoing CS with LAA-closure alone. Therefore, a concomitant LAA closure during CS without additional surgical ablation does not show any clinical benefit in terms of reduced stroke rate until 12 and 24 months follow-up.
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