Background:
Stroke is a major adverse event in patients developing atrial fibrillation (AF) after cardiac surgery. Left atrial appendage (LAA) closure using devices is expected to prevent stroke and enable patients to be warfarin free; however, problems such as procedure-related adverse events and possible residual flow remain unsolved. Concomitant “surgical” LAA amputation/ligation (LAA-A/L) during off-pump coronary artery bypass grafting (OPCAB) is actively performed in our institution.
Methods:
This is a prospective observational study of 578 consecutive patients (mean age 69 ± 9.8 years, Male 82%) undergoing OPCAB with or without concomitant LAA-A/L from 2011 to 2014. The safety and efficacy of the concomitant procedure, performed on 193 (33%) patients, on preventing early (<30 days) and late postoperative stroke were examined.
Results:
LAA was amputated in 154 patients (80%), and ligated in 39 (20%). Between patients with and without LAA-A/L, no difference was seen in the preoperative characteristics including CHADS2 and CHA2DS2-VASc scores, and no significant differences in their operative time, requirement of blood transfusion, length of ICU and total hospital stay were noted. The incidence of postoperative AF was not different (33% vs. 28%, p=0.18), and early and late stroke incidences were not significantly different between the groups (1.0% vs. 0.8%, p=0.75, 2.2% vs. 2.8% p=0.67, respectively). However, in patients without LAA-A/L, both early and late stroke occurred more frequently in those developing AF (2.8% vs. 0%, p=0.005, 6.2% vs. 1.5%; p=0.017, respectively), while stroke incidence in patients receiving LAA-A/L, was not significantly different between those with and without postoperative AF (0.8% vs. 1.6%, p=0.61, 1.6% vs. 2.5%; p=0.69, respectively). Multivariate logistic regression showed postoperative AF without LAA-A/L as the only independent positive predictor of early (OR: 6.8; 95% CI: 1.11 to 52.60; p=0.04) and late (OR: 3.7; 95% CI: 1.18 to 10.94; p=0.03) stroke.
Conclusions:
Concomitant LAA-A/L with OPCAB is safe and effective for stroke prevention in patients developing postoperative AF. This preventative procedure seems beneficial, since AF is the most common arrhythmia associated with the risk of stroke.
A new method of left atrial appendage occlusion for the prevention of thromboembolic complications in patients with atrial fibrillation during coronary artery bypass grafting
