Routine left atrial appendage closure: a retrospective analysis of mid-term outcomes

Abstract

Background: There is strong evidence that stroke associated with atrial fibrillation (AF) has a cardioembolic origin. Given that the main source of thrombi in such patients is the left atrial appendage (LAA), there is a prospect of its closure becoming an adjunct or alternative to lifelong anticoagulant therapy.Objective: To evaluate the long-term effectiveness of routine LAA closure for ischemic stroke (IS) prevention in patients who underwent cardiac surgery with cardiopulmonary bypass (CPB).Methods: Our retrospective single-center study included patients who underwent cardiac surgery with CPB within 3 years. All participants were older than 18 years. The exclusion criteria: lack of information on the long-term outcomes; hemodynamically significant lesion of brachiocephalic vessels; porcelain aorta; infective endocarditis; history of malignant neoplasms, autoimmune diseases, and systemic vasculitis; acute coronary syndrome, repeated open heart surgery, and minimally invasive procedures. The selected patients were divided into 2 groups. Group 1 included patients who underwent concomitant LAA closure. Group 2 consisted of patients with intact LAA. We further divided patients based on whether they had preoperative AF or not. The primary end point was IS. The secondary end points were survival, perioperative myocardial infarction and AF, CPB and aortic cross-clamp time, number of resternotomies for bleeding, length of stay in the intensive care and cardiac surgery units.Results: After the primary analysis and use of exclusion criteria, we formed an LAA closure group (216 patients) and a group with intact LAA (179 patients). Among 129 patients with preoperative AF, concomitant LAA closure was performed in 69 patients and was not performed in 60 patients. Among 266 patients with no history of AF, this procedure was performed in 147 patients and was not performed in 119 patients. Multivariable Cox regression analysis included all the patients and showed that LAA closure was an independent predictor of decrease in IS incidence (hazard ratio, 0.20; 95% CI, 0.06-0.62; P = .006). At the same time, the procedure lost its benefits when patients with AF were excluded from the analysis. There were no differences in the secondary end points.Conclusion: LAA closure is an effective and safe method for long-term IS prevention in patients with AF operated on using CPB. The use of this procedure as a routine addition to the main cardiac surgery is not viable. Received 12 December 2022. Revised 4 September 2023. Accepted 5 September 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.