Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: the LAACS randomized study

Jesper Park-Hansen, Susanne J V Holme, Akhmadjon Irmukhamedov, Christian L Carranza, Anders M Greve, Gina Al-Farra, Robert G C Riis, Brian Nilsson, Johan S R Clausen, Anne S Nørskov, Christina R Kruuse, Egill Rostrup, Helena Dominguez, Jesper Park-Hansen, Susanne J V Holme, Akhmadjon Irmukhamedov, Christian L Carranza, Anders M Greve, Gina Al-Farra, Robert G C Riis, Brian Nilsson, Johan S R Clausen, Anne S Nørskov, Christina R Kruuse, Egill Rostrup, Helena Dominguez

Abstract

Background: Open heart surgery is associated with high occurrence of atrial fibrillation (AF), subsequently increasing the risk of post-operative ischemic stroke. Concomitant with open heart surgery, a cardiac ablation procedure is commonly performed in patients with known AF, often followed by left atrial appendage closure with surgery (LAACS). However, the protective effect of LAACS on the risk of cerebral ischemia following cardiac surgery remains controversial. We have studied whether LAACS in addition to open heart surgery protects against post-operative ischemic brain injury regardless of a previous AF diagnosis.

Methods: One hundred eighty-seven patients scheduled for open heart surgery were enrolled in a prospective, open-label clinical trial and randomized to concomitant LAACS vs. standard care. Randomization was stratified by usage of oral anticoagulation (OAC) planned to last at least 3 months after surgery. The primary endpoint was a composite of post-operative symptomatic ischemic stroke, transient ischemic attack or imaging findings of silent cerebral ischemic (SCI) lesions.

Results: During a mean follow-up of 3.7 years, 14 (16%) primary events occurred among patients receiving standard surgery vs. 5 (5%) in the group randomized to additional LAACS (hazard ratio 0.3; 95% CI: 0.1-0.8, p = 0.02). In per protocol analysis (n = 141), 14 (18%) primary events occurred in the control group vs. 4 (6%) in the LAACS group (hazard ratio 0.3; 95% CI: 0.1-1.0, p = 0.05).

Conclusions: In a real-world setting, LAACS in addition to elective open-heart surgery was associated with lower risk of post-operative ischemic brain injury. The protective effect was not conditional on AF/OAC status at baseline.

Trial registration: LAACS study, clinicaltrials.gov NCT02378116 , March 4th 2015, retrospectively registered.

Keywords: Atrial fibrillation; Heart surgery; Left atrial appendage closure; Stroke.

Conflict of interest statement

Ethics approval and consent to participate

The study was accepted by the National Ethics Committee in Denmark (H-3-2010-017). All subjects provided a signed informed consent for participation and accepted the publication of the results.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Cumulative probability of primary events (combined ischemic stroke, transitory ischemic stroke or silent ischemic images) according to randomized LAACS (left atrial appendage closure with surgery)
Fig. 2
Fig. 2
Cumulative probability of symptomatic ischemic stroke or transient ischemic attack (image findings excluded) according to randomized LAACS (left atrial appendage closure with surgery)

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