Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation: a national cohort study

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

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Purpose: Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO. Methods: In a nationally-representative, contemporary cohort (07/2011–06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models. Results: In this cohort (average age, 76 years; 39% female), 4177 (37%) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25% (“unprotected” patients). The overall propensity for S-LAAO decreased significantly with increasing CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (ptrend < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers. Conclusions: Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA2DS2-VASc score-defined stroke risk).

Original languageEnglish (US)
JournalJournal of Interventional Cardiac Electrophysiology
DOIs
StateAccepted/In press - Jan 1 2019

Fingerprint

Atrial Appendage
Atrial Fibrillation
Thoracic Surgery
Cohort Studies
Stroke
Linear Models
Thromboembolism
Transient Ischemic Attack
Medicare
Vascular Diseases
Diabetes Mellitus
Heart Failure
Logistic Models
Databases
Hypertension

Keywords

  • Arrhythmia therapy (including ablation
  • Atrial fibrillation
  • Atrial flutter
  • Drugs)
  • Surgery

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation : a national cohort study. / Friedman, Daniel J.; Gaca, Jeffrey G.; Wang, Tongrong; Malaisrie, S. Chris; Holmes, David; Piccini, Jonathan P.; Suri, Rakesh M.; Mack, Michael J.; Badhwar, Vinay; Jacobs, Jeffrey P.; Peterson, Eric D.; Chow, Shein Chung; Matthew Brennan, J.

In: Journal of Interventional Cardiac Electrophysiology, 01.01.2019.

Research output: Contribution to journalArticle

Friedman, Daniel J. ; Gaca, Jeffrey G. ; Wang, Tongrong ; Malaisrie, S. Chris ; Holmes, David ; Piccini, Jonathan P. ; Suri, Rakesh M. ; Mack, Michael J. ; Badhwar, Vinay ; Jacobs, Jeffrey P. ; Peterson, Eric D. ; Chow, Shein Chung ; Matthew Brennan, J. / Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation : a national cohort study. In: Journal of Interventional Cardiac Electrophysiology. 2019.
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abstract = "Purpose: Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO. Methods: In a nationally-representative, contemporary cohort (07/2011–06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models. Results: In this cohort (average age, 76 years; 39{\%} female), 4177 (37{\%}) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25{\%} (“unprotected” patients). The overall propensity for S-LAAO decreased significantly with increasing CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (ptrend < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers. Conclusions: Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA2DS2-VASc score-defined stroke risk).",
keywords = "Arrhythmia therapy (including ablation, Atrial fibrillation, Atrial flutter, Drugs), Surgery",
author = "Friedman, {Daniel J.} and Gaca, {Jeffrey G.} and Tongrong Wang and Malaisrie, {S. Chris} and David Holmes and Piccini, {Jonathan P.} and Suri, {Rakesh M.} and Mack, {Michael J.} and Vinay Badhwar and Jacobs, {Jeffrey P.} and Peterson, {Eric D.} and Chow, {Shein Chung} and {Matthew Brennan}, J.",
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T1 - Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation

T2 - a national cohort study

AU - Friedman, Daniel J.

AU - Gaca, Jeffrey G.

AU - Wang, Tongrong

AU - Malaisrie, S. Chris

AU - Holmes, David

AU - Piccini, Jonathan P.

AU - Suri, Rakesh M.

AU - Mack, Michael J.

AU - Badhwar, Vinay

AU - Jacobs, Jeffrey P.

AU - Peterson, Eric D.

AU - Chow, Shein Chung

AU - Matthew Brennan, J.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Purpose: Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO. Methods: In a nationally-representative, contemporary cohort (07/2011–06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models. Results: In this cohort (average age, 76 years; 39% female), 4177 (37%) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25% (“unprotected” patients). The overall propensity for S-LAAO decreased significantly with increasing CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (ptrend < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers. Conclusions: Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA2DS2-VASc score-defined stroke risk).

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KW - Arrhythmia therapy (including ablation

KW - Atrial fibrillation

KW - Atrial flutter

KW - Drugs)

KW - Surgery

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