Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Cardiovascular Drugs and Therapy
Published in: Cardiovascular Drugs and Therapy 5/2023

23-12-2022 | Stroke | Invited Review Article

Considerations for Left Atrial Appendage Occlusion During Cardiac Surgery

Authors: Christopher B. Sylvester, Vivek Patel, Ravi K. Ghanta, Gabriel Loor

Published in: Cardiovascular Drugs and Therapy | Issue 5/2023

Login to get access

Abstract

Atrial fibrillation is associated with an increased risk of stroke secondary to thrombus formation in the left atrial appendage. Left atrial appendage occlusion (LAAO) is an effective method of reducing the risk of stroke in patients with atrial fibrillation. Although LAAO does not remove the requirement for anticoagulation, it reduces the risk of stroke when compared to anticoagulation alone. We critically analyze the data on LAAO in cardiac surgery. We also discuss the methods of LAAO, the risks of LAAO, and patient populations that could benefit from LAAO. We discuss high-level evidence that LAAO at the time of cardiac surgery reduces the risk of stroke in patients with a history of atrial fibrillation. In patients without a history of atrial fibrillation undergoing cardiac surgery, we suggest that LAAO should be considered in select patients at high risk of atrial fibrillation and stroke, when technically feasible.
Literature
1.
Eikelboom R, Sanjanwala R, Le M-L, Yamashita MH, Arora RC. Postoperative atrial fibrillation after cardiac surgery: a systematic review and meta-analysis. Ann Thorac Surg. 2021;111:544–54.PubMedCrossRef
2.
Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755–9.PubMedCrossRef
3.
Vizzardi E, Curnis A, Latini MG, et al. Risk factors for atrial fibrillation recurrence: a literature review. J Cardiovasc Med. 2014;15:235–53.CrossRef
4.
Gammie JS, Haddad M, Milford-Beland S, et al. Atrial fibrillation correction surgery: lessons from the Society of Thoracic Surgeons National Cardiac Database. Ann Thorac Surg. 2008;85:909–14.PubMedCrossRef
5.
Bowdish ME, D’Agostino RS, Thourani VH, et al. STS adult cardiac surgery database: 2021 Update on Outcomes, Quality, and Research. Ann Thorac Surg. 2021;111:1770–80.PubMedCrossRef
6.
Lin M-H, Kamel H, Singer DE, Wu Y-L, Lee M, Ovbiagele B. Perioperative/postoperative atrial fibrillation and risk of subsequent stroke and/or mortality: a meta-analysis. Stroke. 2019;50:1364–71.PubMedCrossRef
7.
Gaudino M, Sanna T, Ballman KV, et al. Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial. The Lancet. 2021;398:2075–83.CrossRef
8.
Tarakji KG, Iii JFS, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305:381–90.PubMedCrossRef
9.
Sultan I, Bianco V, Kilic A, et al. Predictors and outcomes of ischemic stroke after cardiac surgery. Ann Thorac Surg. 2020;110:448–56.PubMedCrossRef
10.
Li R, White CM, Mehmeti J, Martin ST, Hobbs LC. Impact of a perioperative prophylaxis guideline on post–cardiothoracic surgery atrial fibrillation. Ann Pharmacother. 2017;51:743–50.PubMedCrossRef
11.
Pollock BD, Filardo G, da Graca B, et al. Predicting new-onset post-coronary artery bypass graft atrial fibrillation with existing risk scores. Ann Thorac Surg. 2018;105:115–21.PubMedCrossRef
12.
Tran DTT, Perry JJ, Dupuis J-Y, Elmestekawy E, Wells GA. Predicting new-onset postoperative atrial fibrillation in cardiac surgery patients. J Cardiothorac Vasc Anesth. 2015;29:1117–26.PubMedCrossRef
13.
Raghavan D, Gao A, Ahn C, et al. Contemporary analysis of incidence of post-operative atrial fibrillation, its predictors, and association with clinical outcomes in lung transplantation. J Heart Lung Transplant. 2015;34:563–70.PubMedCrossRef
14.
Litwinowicz R, Filip G, Sobczyk D, et al. Long-term effect of anticoagulation following left atrial appendage occlusion with the LARIAT device in patients with nonvalvular atrial fibrillation: impact on thromboembolism, bleeding and mortality. Real life data Adv Interv Cardiol. 2020;16:89–96.
15.
Lakkireddy D, Sridhar Mahankali A, Kanmanthareddy A, et al. Left atrial appendage ligation and ablation for persistent atrial fibrillation. JACC Clin Electrophysiol. 2015;1:153–60.PubMedCrossRef
16.
Swaans MJ, Post MC, Rensing BJWM, Boersma LVA. Ablation for atrial fibrillation in combination with left atrial appendage closure: first results of a feasibility study. J Am Heart Assoc. 2012;1:e002212.PubMedPubMedCentralCrossRef
17.
January CT, Wann LS, Calkins H, et al. AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;2019:140.
18.
Badhwar V, Rankin JS, Damiano RJ, et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg. 2017;103:329–41.PubMedCrossRef
19.
Healey JS, Crystal E, Lamy A, et al. 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.PubMedCrossRef
20.
Whitlock RP, Vincent J, Blackall MH, et al. Left atrial appendage occlusion study II (LAAOS II). Can J Cardiol. 2013;29:1443–7.PubMedCrossRef
21.
Whitlock RP, Belley-Cote EP, Paparella D, et al. Left atrial appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med. 2021;384:2081–91.PubMedCrossRef
22.
Yao X, Gersh BJ, Holmes DR, et al. Association of surgical left atrial appendage occlusion with subsequent Stroke and mortality among patients undergoing cardiac surgery. JAMA. 2018;319:2116.PubMedPubMedCentralCrossRef
23.
Friedman DJ, Piccini JP, Wang T, et al. Association between left atrial appendage occlusion and readmission for thromboembolism among patients with atrial fibrillation undergoing concomitant cardiac surgery. JAMA. 2018;319:365.PubMedPubMedCentralCrossRef
24.
Ando M, Funamoto M, Cameron DE, Sundt TM. Concomitant surgical closure of left atrial appendage: A systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2018;156:1071-1080.e2.PubMedCrossRef
25.
Ibrahim AM, Tandan N, Koester C, et al. Meta-analysis evaluating outcomes of surgical left atrial appendage occlusion during cardiac surgery. Am J Cardiol. 2019;124:1218–25.PubMedCrossRef
26.
Madden JL. Resection of the left auricular appendix: a prophylaxis for recurrent arterial emboli. JAMA. 1949;140:769.CrossRef
27.
Holmes DR, Alkhouli M. The history of the left atrial appendage occlusion. Card Electrophysiol Clin. 2020;12:1–11.PubMedCrossRef
28.
Sievert H, Lesh MD, Trepels T, et al. Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation: early clinical experience. Circulation. 2002;105:1887–9.PubMedCrossRef
29.
Moss JD. Left Atrial appendage exclusion for prevention of stroke in atrial fibrillation: review of minimally invasive approaches. Curr Cardiol Rep. 2014;16:448.PubMedCrossRef
30.
Mahmood E, Matyal R, Mahmood F, et al. Impact of left atrial appendage exclusion on short-term outcomes in isolated coronary artery bypass graft surgery. Circulation. 2020;142:20–8.PubMedCrossRef
31.
Munir MB, Khan MZ, Darden D, et al. Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States. J Cardiovasc Electrophysiol. 2021;32:83–92.PubMedCrossRef
32.
Lee R, Vassallo P, Kruse J, et al. A randomized, prospective pilot comparison of 3 atrial appendage elimination techniques: Internal ligation, stapled excision, and surgical excision. J Thorac Cardiovasc Surg. 2016;152:1075–80.PubMedCrossRef
33.
Toale C, Fitzmaurice GJ, Eaton D, Lyne J, Redmond KC. Outcomes of left atrial appendage occlusion using the AtriClip device: a systematic review. Interact Cardiovasc Thorac Surg. 2019;29:655–62.PubMedCrossRef
34.
35.
van Praet KM, Nerseian G, Kofler M, et al. Minimally invasive approach to the treatment of atrial fibrillation: Concomitant Convergent and LARIAT procedure. Multimed Man Cardio-Thorac Surg [Internet]. 2022 [cited 2022 Oct 23]; . Available from: https://​mmcts.​org/​tutorial/​1712
36.
Suwalski P, Witkowska A. Totally thoracoscopic left atrial occlusion concomitant to endoscopic atraumatic coronary artery bypass grafting (EACAB). Multimed Man Cardio-Thorac Surg [Internet]. 2018 [cited 2022 Oct 23];2018 . Available from: http://​mmcts.​org/​tutorial/​938
37.
Boersma LV, Ince H, Kische S, et al. Evaluating real-world clinical outcomes in atrial fibrillation patients receiving the WATCHMAN left atrial appendage closure technology: final 2-year outcome data of the EWOLUTION Trial Focusing on History of Stroke and Hemorrhage. Circ Arrhythm Electrophysiol. 2019;12 .
38.
Sievert H, Rasekh A, Bartus K, et al. Left Atrial appendage ligation in nonvalvular atrial fibrillation patients at high risk for embolic events with ineligibility for oral anticoagulation. JACC Clin Electrophysiol. 2015;1:465–74.PubMedCrossRef
39.
Kanderian AS, Gillinov AM, Pettersson GB, Blackstone E, Klein AL. Success of surgical left atrial appendage closure. J Am Coll Cardiol. 2008;52:924–9.PubMedCrossRef
40.
Tsai Y-C, Phan K, Munkholm-Larsen S, Tian DH, La Meir M, Yan TD. Surgical left atrial appendage occlusion during cardiac surgery for patients with atrial fibrillation: a meta-analysis. Eur J Cardiothorac Surg. 2015;47:847–54.PubMedCrossRef
41.
Yoshihara F, Nishikimi T, Kosakai Y, et al. Atrial natriuretic peptide secretion and body fluid balance after bilateral atrial appendectomy by the maze procedure. J Thorac Cardiovasc Surg. 1998;116:213–9.PubMedCrossRef
42.
Yoshihara F, Nishikimi T, Sasako Y, et al. Preservation of the right atrial appendage improves reduced plasma atrial natriuretic peptide levels after the maze procedure. J Thorac Cardiovasc Surg. 2000;119:790–4.PubMedCrossRef
43.
Melduni RM, Schaff HV, Lee H-C, et al. 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.PubMedCrossRef
44.
Yao X, Abraham NS, Alexander GC, et al. Effect of adherence to oral anticoagulants on risk of stroke and major bleeding among patients with atrial fibrillation. J Am Heart Assoc. 2016;5 .
45.
O’Brien EC, Holmes DN, Ansell JE, et al. Physician practices regarding contraindications to oral anticoagulation in atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry. Am Heart J. 2014;167:601-609.e1.PubMedCrossRef
46.
Piccini JP, Sievert H, Patel MR. Left atrial appendage occlusion: rationale, evidence, devices, and patient selection. Eur Heart J. 2016;869–76 .
47.
van den Berg NWE, Neefs J, Berger WR, et al. PREventive left atrial appenDage resection for the predICtion of fuTure atrial fibrillation: design of the PREDICT AF study. J Cardiovasc Med. 2019;20:752–61.CrossRef
48.
Hawkins RB, Mehaffey JH, Guo A, et al. Postoperative atrial fibrillation is associated with increased morbidity and resource utilization after left ventricular assist device placement. J Thorac Cardiovasc Surg. 2018;156:1543-1549.e4.PubMedPubMedCentralCrossRef
49.
Deshmukh A, Bhatia A, Anyanwu E, et al. Incidence and outcomes of postoperative atrial fibrillation after left ventricular assist device. ASAIO J Am Soc Artif Intern Organs. 2018;64:581–5.CrossRef
50.
Deshmukh A, Bhatia A, Sayer GT, et al. Left atrial appendage occlusion with left ventricular assist device decreases thromboembolic events. Ann Thorac Surg. 2019;107:1181–6.PubMedCrossRef
51.
Lewis RS, Wang L, Spinelli KJ, Ott GY, Abraham J. Surgical occlusion of the left atrial appendage and thromboembolic complications in patients with left ventricular assist devices. J Heart Lung Transplant. 2017;36:586–8.PubMedCrossRef
52.
Al-abcha A, Saleh Y, Elsayed M, et al. Left atrial appendage closure versus oral anticoagulation in non-valvular atrial fibrillation: a systematic review and meta-analysis. Cardiovasc Revasc Med. 2022;36:18–24.PubMedCrossRef
53.
Reddy VY, Doshi SK, Kar S, et al. 5-year outcomes after left atrial appendage closure. J Am Coll Cardiol. 2017;70:2964–75.PubMedCrossRef
Metadata
Title
Considerations for Left Atrial Appendage Occlusion During Cardiac Surgery
Authors
Christopher B. Sylvester
Vivek Patel
Ravi K. Ghanta
Gabriel Loor
Publication date
23-12-2022
Publisher
Springer US
Published in
Cardiovascular Drugs and Therapy / Issue 5/2023
Print ISSN: 0920-3206
Electronic ISSN: 1573-7241
DOI
https://doi.org/10.1007/s10557-022-07415-y

Other articles of this Issue 5/2023

Cardiovascular Drugs and Therapy 5/2023 Go to the issue

Original Article

Platelet-Mediated Transfer of Cardioprotection by Remote Ischemic Conditioning and Its Abrogation by Aspirin But Not by Ticagrelor

Trial Designs

Platelet Inhibition with Ticagrelor 60 mg Versus 90 mg Twice Daily in Elderly Patients with Acute Coronary Syndrome: Rationale and Design of the PLINY THE ELDER Trial

Editorial

Trimetazidine to Reduce Myocardial Fibrosis—Competing Interests with SGLT2 Inhibitors?

Original Article

CXCR7 Agonist TC14012 Improves Angiogenic Function of Endothelial Progenitor Cells via Activating Akt/eNOS Pathway and Promotes Ischemic Angiogenesis in Diabetic Limb Ischemia

Review Article

Antiplatelet Therapy in End-stage Renal Disease Patients on Maintenance Dialysis: a State-of-the-art Review

Original Article

Implications of ACC/AHA Versus ESC/EAS LDL-C Recommendations for Residual Risk Reduction in ASCVD: A Simulation Study From DA VINCI