Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery

Daniel J. Friedman, Jonathan P. Piccini, Tongrong Wang, Jiayin Zheng, S. Chris Malaisrie, David Holmes, Rakesh M. Suri, Michael J. Mack, Vinay Badhwar, Jeffrey P. Jacobs, Jeffrey G. Gaca, Shein Chung Chow, Eric D. Peterson, J. Matthew Brennan

Research output: Contribution to journalArticle

35 Citations (Scopus)

Abstract

IMPORTANCE The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism. OBJECTIVE To evaluate the association of S-LAAO vs no receipt of S-LAAO with the risk of thromboembolism among older patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged 65 years and older with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014. EXPOSURES S-LAAO vs no S-LAAO. MAIN OUTCOMES AND MEASURES The primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years of follow-up, as defined by Medicare claims data. Secondary end points included hemorrhagic stroke, all-cause mortality, and a composite end point (thromboembolism, hemorrhagic stroke, or all-cause mortality). RESULTS Among 10 524 patients undergoing surgery (median age, 76 years; 39% female; median CHA2DS2-VASc score, 4), 3892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, all-cause mortality in 21.5%, and the composite end point in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs 6.2%), all-cause mortality (17.3% vs 23.9%), and the composite end point (20.5% vs 28.7%) but no significant difference in rates of hemorrhagic stroke (0.9% vs 0.9%). After inverse probability–weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95% CI, 0.56-0.81; P < .001), all-cause mortality (HR, 0.88; 95% CI, 0.79-0.97; P = .001), and the composite end point (HR, 0.83; 95% CI, 0.76-0.91; P < .001) but not hemorrhagic stroke (subdistribution HR, 0.84; 95% CI, 0.53-1.32; P = .44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2% vs 6.0%; adjusted subdistribution HR, 0.26; 95% CI, 0.17-0.40; P < .001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1% vs 6.3%; adjusted subdistribution HR, 0.88; 95% CI, 0.56-1.39; P = .59). CONCLUSIONS AND RELEVANCE Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years. These findings support the use of S-LAAO, but randomized trials are necessary to provide definitive evidence.

Original languageEnglish (US)
Pages (from-to)365-374
Number of pages10
JournalJAMA - Journal of the American Medical Association
Volume319
Issue number4
DOIs
StatePublished - Jan 23 2018

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Atrial Appendage
Thromboembolism
Atrial Fibrillation
Thoracic Surgery
Stroke
Mortality
Coronary Artery Bypass
Medicare
Transient Ischemic Attack

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery. / Friedman, Daniel J.; Piccini, Jonathan P.; Wang, Tongrong; Zheng, Jiayin; Malaisrie, S. Chris; Holmes, David; Suri, Rakesh M.; Mack, Michael J.; Badhwar, Vinay; Jacobs, Jeffrey P.; Gaca, Jeffrey G.; Chow, Shein Chung; Peterson, Eric D.; Brennan, J. Matthew.

In: JAMA - Journal of the American Medical Association, Vol. 319, No. 4, 23.01.2018, p. 365-374.

Research output: Contribution to journalArticle

Friedman, DJ, Piccini, JP, Wang, T, Zheng, J, Malaisrie, SC, Holmes, D, Suri, RM, Mack, MJ, Badhwar, V, Jacobs, JP, Gaca, JG, Chow, SC, Peterson, ED & Brennan, JM 2018, 'Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery', JAMA - Journal of the American Medical Association, vol. 319, no. 4, pp. 365-374. https://doi.org/10.1001/jama.2017.20125
Friedman, Daniel J. ; Piccini, Jonathan P. ; Wang, Tongrong ; Zheng, Jiayin ; Malaisrie, S. Chris ; Holmes, David ; Suri, Rakesh M. ; Mack, Michael J. ; Badhwar, Vinay ; Jacobs, Jeffrey P. ; Gaca, Jeffrey G. ; Chow, Shein Chung ; Peterson, Eric D. ; Brennan, J. Matthew. / Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery. In: JAMA - Journal of the American Medical Association. 2018 ; Vol. 319, No. 4. pp. 365-374.
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abstract = "IMPORTANCE The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism. OBJECTIVE To evaluate the association of S-LAAO vs no receipt of S-LAAO with the risk of thromboembolism among older patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged 65 years and older with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014. EXPOSURES S-LAAO vs no S-LAAO. MAIN OUTCOMES AND MEASURES The primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years of follow-up, as defined by Medicare claims data. Secondary end points included hemorrhagic stroke, all-cause mortality, and a composite end point (thromboembolism, hemorrhagic stroke, or all-cause mortality). RESULTS Among 10 524 patients undergoing surgery (median age, 76 years; 39{\%} female; median CHA2DS2-VASc score, 4), 3892 (37{\%}) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4{\%}, hemorrhagic stroke in 0.9{\%}, all-cause mortality in 21.5{\%}, and the composite end point in 25.7{\%}. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2{\%} vs 6.2{\%}), all-cause mortality (17.3{\%} vs 23.9{\%}), and the composite end point (20.5{\%} vs 28.7{\%}) but no significant difference in rates of hemorrhagic stroke (0.9{\%} vs 0.9{\%}). After inverse probability–weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95{\%} CI, 0.56-0.81; P < .001), all-cause mortality (HR, 0.88; 95{\%} CI, 0.79-0.97; P = .001), and the composite end point (HR, 0.83; 95{\%} CI, 0.76-0.91; P < .001) but not hemorrhagic stroke (subdistribution HR, 0.84; 95{\%} CI, 0.53-1.32; P = .44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2{\%} vs 6.0{\%}; adjusted subdistribution HR, 0.26; 95{\%} CI, 0.17-0.40; P < .001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1{\%} vs 6.3{\%}; adjusted subdistribution HR, 0.88; 95{\%} CI, 0.56-1.39; P = .59). CONCLUSIONS AND RELEVANCE Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years. These findings support the use of S-LAAO, but randomized trials are necessary to provide definitive evidence.",
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TY - JOUR

T1 - Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery

AU - Friedman, Daniel J.

AU - Piccini, Jonathan P.

AU - Wang, Tongrong

AU - Zheng, Jiayin

AU - Malaisrie, S. Chris

AU - Holmes, David

AU - Suri, Rakesh M.

AU - Mack, Michael J.

AU - Badhwar, Vinay

AU - Jacobs, Jeffrey P.

AU - Gaca, Jeffrey G.

AU - Chow, Shein Chung

AU - Peterson, Eric D.

AU - Brennan, J. Matthew

PY - 2018/1/23

Y1 - 2018/1/23

N2 - IMPORTANCE The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism. OBJECTIVE To evaluate the association of S-LAAO vs no receipt of S-LAAO with the risk of thromboembolism among older patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged 65 years and older with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014. EXPOSURES S-LAAO vs no S-LAAO. MAIN OUTCOMES AND MEASURES The primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years of follow-up, as defined by Medicare claims data. Secondary end points included hemorrhagic stroke, all-cause mortality, and a composite end point (thromboembolism, hemorrhagic stroke, or all-cause mortality). RESULTS Among 10 524 patients undergoing surgery (median age, 76 years; 39% female; median CHA2DS2-VASc score, 4), 3892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, all-cause mortality in 21.5%, and the composite end point in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs 6.2%), all-cause mortality (17.3% vs 23.9%), and the composite end point (20.5% vs 28.7%) but no significant difference in rates of hemorrhagic stroke (0.9% vs 0.9%). After inverse probability–weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95% CI, 0.56-0.81; P < .001), all-cause mortality (HR, 0.88; 95% CI, 0.79-0.97; P = .001), and the composite end point (HR, 0.83; 95% CI, 0.76-0.91; P < .001) but not hemorrhagic stroke (subdistribution HR, 0.84; 95% CI, 0.53-1.32; P = .44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2% vs 6.0%; adjusted subdistribution HR, 0.26; 95% CI, 0.17-0.40; P < .001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1% vs 6.3%; adjusted subdistribution HR, 0.88; 95% CI, 0.56-1.39; P = .59). CONCLUSIONS AND RELEVANCE Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years. These findings support the use of S-LAAO, but randomized trials are necessary to provide definitive evidence.

AB - IMPORTANCE The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism. OBJECTIVE To evaluate the association of S-LAAO vs no receipt of S-LAAO with the risk of thromboembolism among older patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged 65 years and older with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014. EXPOSURES S-LAAO vs no S-LAAO. MAIN OUTCOMES AND MEASURES The primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years of follow-up, as defined by Medicare claims data. Secondary end points included hemorrhagic stroke, all-cause mortality, and a composite end point (thromboembolism, hemorrhagic stroke, or all-cause mortality). RESULTS Among 10 524 patients undergoing surgery (median age, 76 years; 39% female; median CHA2DS2-VASc score, 4), 3892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, all-cause mortality in 21.5%, and the composite end point in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs 6.2%), all-cause mortality (17.3% vs 23.9%), and the composite end point (20.5% vs 28.7%) but no significant difference in rates of hemorrhagic stroke (0.9% vs 0.9%). After inverse probability–weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95% CI, 0.56-0.81; P < .001), all-cause mortality (HR, 0.88; 95% CI, 0.79-0.97; P = .001), and the composite end point (HR, 0.83; 95% CI, 0.76-0.91; P < .001) but not hemorrhagic stroke (subdistribution HR, 0.84; 95% CI, 0.53-1.32; P = .44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2% vs 6.0%; adjusted subdistribution HR, 0.26; 95% CI, 0.17-0.40; P < .001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1% vs 6.3%; adjusted subdistribution HR, 0.88; 95% CI, 0.56-1.39; P = .59). CONCLUSIONS AND RELEVANCE Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years. These findings support the use of S-LAAO, but randomized trials are necessary to provide definitive evidence.

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