Left Atrial Appendage Amputation for Stroke Prevention in Atrial Fibrillation Patients

Objectives: Patients with nonvalvular atrial fibrillation (AF) are at increased risk for thromboembolic events, with the left atrial appendage (LAA) as the main source of thrombi. Therefore, we examined whether concomitant LAA amputation (LAAamp) with Stapler device in AF patients undergoing any type of aortic valve replacement (AVR) lowers the incidence of cerebrovascular insult (CVI).

Methods: Two subcohorts were generated retrospectively from initial 137 patients with AF undergoing surgical aortic valve replacement isolated or combined with revascularization: one group with LAAamp (n = 65) and the second without designated as no-LAAamp (n = 72). Data were collected from institutional data system and follow-up was done by telephone interview. Primary endpoints were defined as CVI (stroke or transient ischemic attack) occurring postoperatively (30 days) or during a median follow-up of 2.16 years (min: 1.37; max: 4.48). The occurrence of pericardial tamponade, 30-day in-hospital mortality and mean intensive care unit (ICU) stay was evaluated. Cox regression was performed as covariate analysis by including variables LAAamp, AF ablation, CHADsVASc Score, history of CVI, rhythm, antiplatelet and anticoagulants. Quality of life was assessed using the EQ-5D-3L questionnaire.

Result: Follow-up was completed in 89.3% (118/132) of the final Cohort. Patients with LAAamp exhibited significantly lower incidence of CVI during follow-up (4.8 vs. 17.4%; odds ratio [OR]: 0.25; 95% confidence interval [CI]: 0.05; 0.84; p = 0.045) and remained the only significant variable also in the Cox regression model (p = 0.019). In contrast, no significant differences were observed in postoperative CVI (1.6 vs. 2.9%; OR: 0.58; 95% CI: 0.02; 7.28; p = 1.000), postoperative outcome (pericardial tamponade: 3.2 vs. 2.9%, p = 1.000; in-hospital mortality: 3.1 vs. 4.3%, p = 0.682; median ICU stay: 2.00 (1.00; 5.00) versus 2.00 (1.00; 4.00) days, p = 0.896) and QoL measures in LAAamp versus no-LAAamp, respectively.

Conclusion: Patients with AF undergoing cardiac surgery and LAAamp exhibit significant reduction of CVI in the follow-up compared with patients without LAAamp irrespective of anticoagulation strategy, ablation and rhythm status. A trend toward lower mortality and CVI was observed also early postoperatively. Therefore, LAAamp should be considered in these patients.

Publication History

Article published online:
19 February 2021