ACC 2021 | LAAOS III: Appendage Closure During Central Vascular Surgery

According to the LAAOS III study, presented at the American College of Cardiology (ACC) 2021 Congress and simultaneously published in the New England Journal of Medicine (NEJM), patients with atrial fibrillation who undergo central vascular surgery for any other indication find benefit in appendage closure during said surgery.

ACC 2021 | LAAOS III: Cierre de orejuela durante una cirugía vascular central

Using oral anticoagulation agents, patients undergoing appendage closure had a rate of stroke and systemic embolism of 4.8% vs. 7% for patients whose appendages were left untouched. This difference is highly significant (hazard ratio [HR]: 0.67; 95% confidence interval [CI]: 0.53-0.85).

This work provides definite information about the benefits of appendage closure in terms of stroke in patients with atrial fibrillation. The benefit is even greater if the peri-operative period is excluded.

Current American and European guidelines provide a class 2B recommendation to appendage closure during surgery. These new data is bound to change this recommendation.

The LAAOS III study was conducted in 105 centers in 27 countries and was designed to provide definite information on the topic—which it ultimately did.

After randomizing 5000 patients, the safety committee recommended interrupting the study due to the clear benefit observed in the active arm.

Read also: ACC 2021 | Stress Increases Events in Young Patients with Prior MI.

All included patients had atrial fibrillation, a CHA2DS2-VASc score ≥2, and an indication for cardiac surgery.

About two thirds of patients underwent valvular surgery and 20% had isolated myocardial revascularization surgery. 

Up to 30% of patients had prior ablation resulting from their atrial fibrillation. Pump time (119 vs. 113 min) and clamp duration (86 vs. 82 min; p < 0.001) were significantly longer in the active arm, but accounted for only five extra minutes, which were worth it.

Read also: Is Rheumatic Etiology Counter Indicated for TAVR?

While all techniques for appendage surgical closure were allowed in the protocol, the most used were amputation and suture closure of the stump.

Closure significantly reduced the chance of stroke and systemic embolism at 3.8 years of follow-up, driven by a lower chance of stroke (4.2% vs. 6.6%; HR: 0.62; 95% CI: 0.48 to 0.80). The curves began to separate a few days after surgery and were completely divergent after 30 days.

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Original Title: Left atrial appendage occlusion during cardiac surgery to prevent stroke.

Reference: R.P. Whitlock et al. Presentado en el ACC 2021 y publicado simultáneamente en NEJM. DOI: 10.1056/NEJMoa2101897.

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