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

Abstract

Background: Prophylactic exclusion of the left atrial appendage (LAA) is often performed during cardiac surgery ostensibly to reduce the risk of stroke. However, the clinical impact of LAA closure in humans remains inconclusive.

Methods: Of 10 633 adults who underwent coronary artery bypass grafting and valve surgery between January 2000 and December 2005, 9792 patients with complete baseline characteristics, surgery procedure, and follow-up data were included in this analysis. A propensity score-matching analysis based on 28 pretreatment covariates was performed and 461 matching pairs were derived and analyzed to estimate the association of LAA closure with early postoperative atrial fibrillation (POAF) (atrial fibrillation ≤30 days of surgery), ischemic stroke, and mortality.

Results: In the propensity-matched cohort, the overall incidence of POAF was 53.9%. In this group, the rate of early POAF among the patients who underwent LAA closure was 68.6% versus 31.9% for those who did not undergo the procedure (P<0.001). LAA closure was independently associated with an increased risk of early POAF (adjusted odds ratio, 3.88; 95% confidence interval, 2.89-5.20), but did not significantly influence the risk of stroke (adjusted hazard ratio, 1.07; 95% confidence interval, 0.72-1.58) or mortality (adjusted hazard ratio, 0.92; 95% confidence interval, 0.75-1.13).

Conclusions: After adjustment for treatment allocation bias, LAA closure during routine cardiac surgery was significantly associated with an increased risk of early POAF, but it did not influence the risk of stroke or mortality. It remains uncertain whether prophylactic exclusion of the LAA is warranted for stroke prevention during non-atrial fibrillation-related cardiac surgery.

Keywords: atrial fibrillation; prevention and control; stroke; survival; thoracic surgery.

© 2016 American Heart Association, Inc.

Figures

Figure 1

Kaplan-Meier analysis showing freedom from ischemic stroke in LAA closure group versus no LAA closure group.A, The survival curves show a significant difference in freedom from stroke in the group with LAA closure versus the group without LAA closure. B, Propensity score-adjusted Kaplan-Meier survival curves based on proportional hazard assumptions for patients who had LAA closure and those who did not have LAA closure show no significant difference in cumulative incidence of stroke between the 2 groups. LAA indicates left atrial appendage.

Figure 2

Kaplan-Meier survival curves of patients who had LAA closure during cardiac surgery versus controls. A, The survival curves show no significant difference in survival in the group with LAA closure versus the group without LAA closure. B, Propensity score-adjusted Kaplan-Meier survival curves show no significant difference in survival between patients who had LAA closure and those who did not. LAA indicates left atrial appendage.