Left atrial appendage preservation versus closure during surgical ablation of atrial fibrillation

Abstract

ObjectiveThere is limited evidence regarding the effectiveness of left atrial appendage (LAA) closure during surgical ablation of atrial fibrillation (AF) in yielding superior clinical outcomes. This study aimed to evaluate the association of LAA closure versus preservation with the risk of adverse clinical outcomes among patients undergoing surgical ablation during cardiac surgery.MethodsWe evaluated 1640 patients (aged 58.8±11.5 years, 898 women) undergoing surgical ablation during cardiac surgery (including mitral valve (MV), n=1378; non-MV, n=262) between 2001 and 2018. Of these, 804 had LAA preserved, and the remaining 836 underwent LAA closure. Comparative risks of stroke and mortality between the two groups were evaluated after adjustments with inverse-probability-of-treatment weighting (IPTW). Longitudinal echocardiographic data (n=9674, 5.9/patient) on transmitral A-wave and E/A-wave ratio were analysed by random coefficient models.ResultsAdjustment with IPTW yielded patient cohorts well-balanced for baseline profiles. During a median follow-up of 43.5 months (IQR 19.0–87.3 months), stroke and death occurred in 87 and 249 patients, respectively. The adjusted risk of stroke (HR 0.85; 95% CI 0.52–1.39) and mortality (HR 0.80; 95% CI 0.61 to 1.05) did not differ significantly between the two groups. Echocardiographic data demonstrated higher transmitral A-wave velocity (group-year interaction, p=0.066) and lower E/A-wave ratio (group-year interaction, p=0.045) in the preservation group than in the closure group.ConclusionsLAA preservation during surgical AF ablation was not associated with an increased risk of stroke or mortality. Postoperative LA transport functions were more favourable with LAA preservation than with LAA closure.

Surgical Ablation for Atrial Fibrillation in Mitral Valve Surgery: Improved Survival and Stroke Risk in US Veterans

“…Ando et al [32] performed a meta-analysis using 7 research articles including almost 3900 patients and observed that LAAO was associated with lower mortality and decreased risk of cerebral vascular accident (CVA) in patients with AF, while a metaanalysis by Tsai et al [33] including 3653 patients showed decreased incidence of stroke and all-cause mortality in the LAAO group. Two large retrospective cohort studies by Lee et al [34] and Kim et al [35] did not demonstrate long-term benefit of LAAO without ablation. The present study demonstrated a lower rate of long-term stroke within the group who underwent LAAO without ablation in comparison to the group that underwent neither ablation nor LAAO.…”

Catheter ablation of atrial fibrillation in the young: a systematic review and meta-analysis

“…Our data revealed that younger patients had smaller atria, which could be a protective factor. And only the older population (21.7%) had LA scars or Low-voltage areas on voltage maps, indicating LA strutural alterations and fibrosis, compared to the very young population, which all had normal voltage maps [20] . Secondly, in older patients, other poor ablation risk factors such as hypertension, obesity, and obstructive sleep apnea syndrome were higher.…”

Cost-effectiveness of left atrial appendage occlusion during cardiac surgery in France: An economic evaluation based on the LAAOS III study

“…However, more recent findings based on real-world evidence have reported conflicting results: in an observational study on 1640 patients who underwent cardiac surgery between 2001 and 2018, Kim et al [24] did not find a difference in the risk of stroke or mortality at 3.5…”