Closing off the Appendage While Performing Cardiac Surgery Results in a Reduction in Risk of Embolic Stroke

Closing off the left appendage as an add-on procedure while performing other cardiac surgery in patients with atrial fibrillation resulted in a reduction in risk of embolic stroke of nearly 40% over 12 months, according to an analysis carried out on the Society of Thoracic Surgeons (STS) database.

Patients who had surgical appendage occlusion had a 15% reduction in all-cause mortality.

The data from the STS database reflects approximately 90% of all cardiothoracic surgery programs in the United States.

This study analyzed 10,524 patients undergoing a first cardiac surgery in 2011 or 2012, either an aortic valve procedure, a mitral valve procedure with or without myocardial revascularization, or isolated myocardial revascularization. All procedures were performed surgically and included clipping, stapling, and excision.

Newer percutaneous methods for closing off the appendage, such as the Watchman or Amplatzer Amulet, were not studied (all patients in the study underwent surgery), but results are significant as proof of the benefit derived from closing the appendage in patients with atrial fibrillation.

Compared with patients who did not undergo occlusion, those who did have it as an add-on procedure to cardiac surgery were more often younger, female, had more commonly permanent atrial fibrillation, and had slightly lower CHA2DS2-VASc and STS scores.

At 1 year, 2.2% of patients in the study were hospitalized for a thromboembolic event (primary endpoint). Rates were lower in the appendage occlusion group than in the untreated group (1.6% vs. 2.5%; adjusted hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.46-0.83).

Similarly, all-cause mortality rates were also lower for the treated group (7% vs. 10.8%; adjusted HR: 0.85; 95% CI: 0.74-0.97), as were rates of the composite endpoint of thromboembolism, hemorrhagic stroke, or death (8.7% vs. 13.5%; adjusted HR: 0.70; 95% CI: 0.70-0.90).

The overall rate of hemorrhagic stroke was low for the entire cohort at just 0.2%.

An exploratory analysis on anticoagulation resulted in a most interesting finding: in the appendage occlusion group that was discharged with no anticoagulant therapy, there was a 71% reduction in the risk of thromboembolism at 1 year. Benefit for this group is even higher than for those who underwent appendage closure associated with anticoagulation.

Randomized studies are certainly needed to ascertain all of this information, particularly the need for anticoagulant agents after closure, and to resist the temptation of applying these results to percutaneous appendage closure.

Original title: Comparative Effectiveness of Left Atrial Appendage Occlusion Among Patients with Atrial Fibrillation Undergoing Concomitant Cardiac Surgery.

Presenter: Friedman DJ.

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