Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation: a national cohort study
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Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO.
In a nationally-representative, contemporary cohort (07/2011–06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models.
In this cohort (average age, 76 years; 39% female), 4177 (37%) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25% (“unprotected” patients). The overall propensity for S-LAAO decreased significantly with increasing CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (ptrend < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers.
Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA2DS2-VASc score-defined stroke risk).
KeywordsArrhythmia therapy (including ablation Surgery Drugs) Atrial fibrillation Atrial flutter
We wish to acknowledge Felicia Graham for longitudinal project leadership, Siyi Zhang and Qingyu Li for statistical support, and Erin Campbell for editorial support.
Sources of funding
Funding for this project was made possible, in part, by the Food and Drug Administration through a grant (1U01FD004591-01), views expressed in written materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does any mention of trade names, commercial practices or organization imply endorsement by the United States Government. Dr. Friedman has been funded via the National Institutes of Health T 32 training grant HL069749.
Compliance with ethical standards
Conflict of interest disclosures
Dr. Brennan holds an Innovation in Regulatory Science Award from Burroughs Welcome Fund. Dr. Friedman has received educational grants from Boston Scientific, Abbott, and Medtronic; research grants from the National Cardiovascular Data Registry and Biosense Webster; was funded by the National Institutes of Health T 32 training grant HL069749-13; and is supported by the Joseph C. Greenfield, Jr., M.D. Scholar in Cardiology Award. Dr. Holmes and the Mayo Clinic report a financial interest in technology related to this research; that technology has been licensed to Boston Scientific. Dr. Piccini reports receiving research grant funding from Boston Scientific. The other authors report no relevant disclosures.
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