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Concomitant Surgical Left Atrial Appendage Occlusion: a Review

  • Invasive Electrophysiology and Pacing (EK Heist, Section Editor)
  • Published:
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Abstract

Purpose of Review

In this review, we discuss some of the observational studies that examined the impact of left atrial appendage occlusion on stroke, the Left Atrial Appendage Occlusion Study (LAAOS) III research program that provided definitive evidence for the benefit of surgical left atrial appendage occlusion on ischemic stroke, and high priority studies in the field that should be pursued by the surgical community.

Recent Findings

Atrial fibrillation is common in patients undergoing cardiac surgery. Oral anticoagulants are effective at preventing strokes related to atrial fibrillation; they have been the standard of care for stroke prevention in patients with atrial fibrillation for decades. Most strokes in patients with atrial fibrillation originate from the left atrial appendage. LAAOS III, a large randomized controlled trial, has recently demonstrated that concomitant left atrial appendage occlusion in patients undergoing cardiac surgery for another indication reduces the risk of stroke or systemic embolism on top of oral anticoagulation.

Summary

Surgical left atrial appendage occlusion reduces the risk of ischemic stroke and systemic embolism in patients with atrial fibrillation and a CHA2DS2-VASc score ≥ 2 undergoing cardiac surgery for another indication. The role of surgical left atrial appendage occlusion with patients without atrial fibrillation, as a substitute to anticoagulation and as a standalone procedure, remains unclear.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med. 1999;131:927–34.

    Article  CAS  Google Scholar 

  2. Whitlock RP, Vincent J, Blackall MH, Hirsh J, Fremes S, Novick R, Devereaux PJ, Teoh K, Lamy A, Connolly SJ, Yusuf S, Carrier M, Healey JS. Left atrial appendage occlusion study II (LAAOS II). Can J Cardiol. 2013;29:1443–7.

    Article  Google Scholar 

  3. Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation. 1991;84:527–39.

    Article  Google Scholar 

  4. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755–9.

    Article  CAS  Google Scholar 

  5. Madden JL. Resection of the left auricular appendix; a prophylaxis for recurrent arterial emboli. J Am Med Assoc. 1949;140:769–72.

    Article  CAS  Google Scholar 

  6. •• Whitlock RP, Belley-Cote EP, Paparella D, Healey JS, Brady K, Sharma M, Reents W, Budera P, Baddour AJ, Fila P, Devereaux PJ, Bogachev-Prokophiev A, Boening A, Teoh KHT, Tagarakis GI, Slaughter MS, Royse AG, McGuinness S, Alings M, Punjabi PP, Mazer CD, Folkeringa RJ, Colli A, Avezum A, Nakamya J, Balasubramanian K, Vincent J, Voisine P, Lamy A, Yusuf S, Connolly SJ and Investigators LI. Left atrial appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med. 2021;384:2081–2091. This is the largest trial of surgical left atrial appendage occlusion demonstrating a 33% reduction in stroke with left atrial appendage occlusion.

  7. Cox JL, Schuessler RB, D'Agostino HJ, Jr., Stone CM, Chang BC, Cain ME, Corr PB, Boineau JP. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991;101:569–83.

  8. Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE, Noseworthy PA, Rosenberg YD, Jeffries N, Mitchell LB, Flaker GC, Pokushalov E, Romanov A, Bunch TJ, Noelker G, Ardashev A, Revishvili A, Wilber DJ, Cappato R, Kuck KH, Hindricks G, Davies DW, Kowey PR, Naccarelli GV, Reiffel JA, Piccini JP, Silverstein AP, Al-Khalidi HR, Lee KL, Investigators C. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: The CABANA randomized clinical trial. JAMA. 2019;321:1261–74.

    Article  CAS  Google Scholar 

  9. • Martin Gutierrez E, Castano M, Gualis J, Martinez-Comendador JM, Maiorano P, Castillo L, Laguna G. Beneficial effect of left atrial appendage closure during cardiac surgery: a meta-analysis of 280 585 patients. Eur J Cardiothor Surg. 2020;57:252–262. Very large systematic review of mostly observational data which found a 33% relative risk reduction with surgical left atrial appendage occlusion.

  10. Yao X, Gersh BJ, Holmes DR Jr, Melduni RM, Johnsrud DO, Sangaralingham LR, Shah ND, Noseworthy PA. Association of surgical left atrial appendage occlusion with subsequent stroke and mortality among patients undergoing cardiac surgery. JAMA. 2018;319:2116–26.

    Article  Google Scholar 

  11. Healey JS, Crystal E, Lamy A, Teoh K, Semelhago L, Hohnloser SH, Cybulsky I, Abouzahr L, Sawchuck C, Carroll S, Morillo C, Kleine P, Chu V, Lonn E, Connolly SJ. Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke. Am Heart J. 2005;150:288–93.

    Article  Google Scholar 

  12. Whitlock RP, Vincent J, Blackall MH, Hirsh J, Fremes S, Novick R, Devereaux PJ, Teoh K, Lamy A, Connolly SJ, Yusuf S, Carrier M, Healey JS. Left Atrial Appendage Occlusion Study II (LAAOS II). Can J Cardiol. 2013;29:1443–7.

    Article  Google Scholar 

  13. Whitlock R, Healey J, Vincent J, Brady K, Teoh K, Royse A, Shah P, Guo Y, Alings M, Folkeringa RJ, Paparella D, Colli A, Meyer SR, Legare JF, Lamontagne F, Reents W, Boning A, Connolly S. Rationale and design of the Left Atrial Appendage Occlusion Study (LAAOS) III. Ann Cardiothorac Surg. 2014;3:45–54.

    PubMed  PubMed Central  Google Scholar 

  14. Melduni RM, Schaff HV, Lee HC, Gersh BJ, Noseworthy PA, Bailey KR, Ammash NM, Cha SS, Fatema K, Wysokinski WE, Seward JB, Packer DL, Rihal CS, Asirvatham SJ. Impact of left atrial appendage closure during cardiac surgery on the occurrence of early postoperative atrial fibrillation, stroke, and mortality: A propensity score-matched analysis of 10 633 patients. Circulation. 2017;135:366–78.

    Article  Google Scholar 

  15. Whitlock R, Healey JS, Connolly SJ, Wang J, Danter MR, Tu JV, Novick R, Fremes S, Teoh K, Khera V, Yusuf S. Predictors of early and late stroke following cardiac surgery. CMAJ. 2014;186:905–11.

    Article  Google Scholar 

  16. Goette A, Kalman JM, Aguinaga L, Akar J, Cabrera JA, Chen SA, Chugh SS, Corradi D, D’Avila A, Dobrev D, Fenelon G, Gonzalez M, Hatem SN, Helm R, Hindricks G, Ho SY, Hoit B, Jalife J, Kim YH, Lip GY, Ma CS, Marcus GM, Murray K, Nogami A, Sanders P, Uribe W, Van Wagoner DR, Nattel S, Document R. EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication. Europace. 2016;18:1455–90.

    Article  Google Scholar 

  17. Ailawadi G, Gerdisch MW, Harvey RL, Hooker RL, Damiano RJ, Jr., Salamon T, Mack MJ. Exclusion of the left atrial appendage with a novel device: early results of a multicenter trial. J Thorac Cardiovasc Surg. 2011;142:1002–9, 1009 e1.

  18. van Laar C, Verberkmoes NJ, van Es HW, Lewalter T, Dunnington G, Stark S, Longoria J, Hofman FH, Pierce CM, Kotecha D, van Putte BP. Thoracoscopic left atrial appendage clipping: A multicenter cohort analysis. JACC Clin Electrophysiol. 2018;4:893–901.

    Article  Google Scholar 

  19. Holmes DR Jr, Doshi SK, Kar S, Price MJ, Sanchez JM, Sievert H, Valderrabano M, Reddy VY. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: A patient-level meta-analysis. J Am Coll Cardiol. 2015;65:2614–23.

    Article  Google Scholar 

  20. Maisel WH. Left atrial appendage occlusion–closure or just the beginning? N Engl J Med. 2009;360:2601–3.

    Article  CAS  Google Scholar 

  21. •• Reddy VY, Doshi SK, Kar S, Gibson DN, Price MJ, Huber K, Horton RP, Buchbinder M, Neuzil P, Gordon NT, Holmes Jr DR. Prevail and Investigators PA. 5-Year Outcomes After Left Atrial Appendage Closure: From the PREVAIL and PROTECT AF Trials. J Am Coll Cardiol. 2017;70:2964–2975. This long-term follow-up represents the best evidence for percutaneous left atrial appendage occlusion.

  22. Hanif H, Belley-Cote EP, Alotaibi A, Dvirnik N, Neupane B, Beyene J, Eikelboom JW, Holmes D, Whitlock RP. Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials. J Cardiovasc Surg (Torino). 2018;59:128–39.

    Google Scholar 

  23. Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, Flaker G, Avezum A, Hohnloser SH, Diaz R, Talajic M, Zhu J, Pais P, Budaj A, Parkhomenko A, Jansky P, Commerford P, Tan RS, Sim KH, Lewis BS, Van Mieghem W, Lip GY, Kim JH, Lanas-Zanetti F, Gonzalez-Hermosillo A, Dans AL, Munawar M, O'Donnell M, Lawrence J, Lewis G, Afzal R, Yusuf S. Committee AS and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011;364:806–17.

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Authors and Affiliations

  1. Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada

    Richard P. Whitlock

  2. Population Health Research Institute, 237 Barton Street E, Hamilton, ON, L8L 2X2, Canada

    Richard P. Whitlock & Emilie P. Belley-Côté

  3. Divisions of Cardiology and Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada

    Emilie P. Belley-Côté

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  1. Richard P. Whitlock
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Correspondence to Richard P. Whitlock.

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Conflict of Interest

Richard P. Whitlock reports grants and other from Boehringer-Ingelheim, other from AtriCure, other from PhaseBio, grants from Bayer, grants from BMS-Pfizer, and other from CryoLife, outside the submitted work. Emilie P. Belley-Côté reports grants from Bayer and BMS-Pfizer, outside the submitted work.

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Whitlock, R.P., Belley-Côté, E.P. Concomitant Surgical Left Atrial Appendage Occlusion: a Review. Curr Cardiol Rep 24, 823–828 (2022). https://doi.org/10.1007/s11886-022-01705-5

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