Perioperative Outcomes of Surgical Left Atrial Appendage Occlusion During Cardiac SurgeryABSTRACT
Surgical left atrial appendage occlusion (S-LAAO) is increasingly performed during cardiac surgery, but perioperative outcomes remain uncertain. Using a nationwide Japanese inpatient database, we analyzed 25,059 adults undergoing valve or coronary bypass surgery (2020 - 2022). After propensity score matching (n = 2,543 each), addition of S-LAAO was not associated with differences in in-hospital mortality, transfusion, reoperation, or 30-day readmission compared to non-S-LAAO group. However, prolonged inotropic support (≥ 2 days) was more frequent with S-LAAO (40.8% vs. 34.7%; odds ratio 1.29, 95% confidence interval: 1.13 - 1.47). Addition of S-LAAO did not increase mortality but was linked to greater inotrope use, warranting further investigation.
Keywords:
Atrial Fibrillation; Thoracic Surgery; Blood Coagulation; Thrombosis.
INTRODUCTION
Atrial fibrillation (AF) is a major risk factor for thromboembolic stroke. Concomitant surgical left atrial appendage occlusion (S-LAAO) at the time of cardiac surgery has gained increasing attention as a preventative strategy. A large randomized controlled trial (the Left Atrial Appendage Occlusion Study or LAAOS III) supported the benefit of S-LAAO in patients with AF who underwent coronary artery bypass graft surgery or valve surgeries[1], and the most recent North American guidelines state that S-LAAO is Class I recommended in patients with AF[2]. In Japan, an additional reimbursement code for concomitant S-LAAO (K594-4) was established in 2020 for patients undergoing planned cardiac surgery who are preoperatively diagnosed with AF or atrial flutter; however, no reports have described the real-world implementation or perioperative outcomes. The efficacy of prophylactic S-LAAO in patients without AF has also been reported[3]. As this practice may become more common, it is increasingly important to investigate strategies to ensure perioperative safety. Therefore, we investigated the effect of S-LAAO during cardiac surgery on perioperative complications, using a nationwide claims database in Japan.
METHODS
This retrospective cross-sectional study used data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (or JROAD-DPC), a nationwide inpatient claims database covering more than 800 Japanese Circulation Society-certified training hospitals during the study period[4]. Patients ≥ 18 years old who underwent valve surgery or coronary artery bypass grafting via median sternotomy or minimally invasive cardiac surgery approach between April 2020 and March 2022 were included. We excluded patients admitted in March, the last month of the fiscal year in Japan, to analyze 30-day re-admission. The study was approved by the Institutional Review Board of the National Cerebral and Cardiovascular Center (R23004, April 9th, 2023). Categorical data are shown as frequencies (%), and continuous data are presented as medians (interquartile ranges). We performed a propensity score (PS) matching analysis separately to compare in-hospital outcomes between S-LAAO and non-S-LAAO. Multivariate logistic regression models were used to calculate the PS representing the probability of undergoing S-LAAO. Baseline characteristics (Table 1) were used as independent variables. Matching was performed using the nearest neighbor algorithm (1:1 without replacement), with a caliper of width 0.2 standard deviations of the logit of the estimated PS. The absolute value of the standardized difference (10%) was considered a relatively small imbalance. To estimate the odds ratio (OR) and 95% confidence intervals (CIs) for in-hospital complications, mixed-effects logistic regression analysis using the institute as a random intercept was performed. All statistical comparisons were two-sided, and P < 0.05 was considered significant. All analyses were performed using STATA 18.0 (StataCorp, College Station, Texas, United States of America).
RESULTS AND DISCUSSION
A total of 25,059 patients (41% female) were included; S-LAAO was performed in 2,543 (10.1%). Although the specific valve involved could not be determined, diagnostic codes for mitral regurgitation (64.0% vs. 43.8%, P < 0.001) and stenosis (9.7% vs. 3.9%, P < 0.001) were significantly more common with S-LAAO than without it, respectively (Table 1). This is consistent with the clinical practice of performing S-LAAO during mitral valve surgery, typically requiring left atrium opening. Patients who underwent S-LAAO were older than those who did not (75 [69 - 79] vs. 72 [65 - 78] years, respectively; P < 0.001), and interventions involving more than one valve were more common with S-LAAO (61.0% vs. 30.0%, P < 0.001). In-hospital death occurred in 3.5% of patients who underwent S-LAAO, comparable to the rate reported in the United States of America[3].
After PS matching, 2,543 patients were included in each group. The standardized differences in the covariates in both cohorts were < 0.1, indicating a well-balanced comparison. Mixed-effects logistic regression analysis in the matched cohort showed no significant association between S-LAAO and in-hospital mortality, transfusion or mechanical circulatory support after surgery (intra-aortic balloon pump, percutaneous axial flow pump, or venoarterial extracorporeal membrane oxygenation), reoperation on the day after the index surgery, and 30-day readmission. S-LAAO was associated with a higher rate of catecholamine use for ≥ 2 days after surgery (40.8% vs. 34.7%, OR [95% CI]: 1.29 [1.13 - 1.47], P < 0.001). The reason for this remains unclear; however, adding S-LAAO to standard cardiac surgery tends to slightly prolong bypass and cross-clamping times[1]. S-LAAO may increase surgical invasiveness and potentially delay postoperative cardiac functional recovery. Further details, such as the dosage and duration of catecholamine use, could not be extracted from the database, highlighting the need for future studies with more granular clinical data.
CONCLUSION
In summary, in a large nationwide Japanese database, adding S-LAAO to cardiac surgery was not associated with mortality or 30-day readmission, but was significantly associated with prolonged catecholamine use, suggesting the need for further investigation.
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This study was carried out at the Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
Artificial Intelligence Usage
The authors declare that no artificial intelligence tool was used in the preparation of this article.
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Sources of FundingThe authors declare that this study was supported by a research grant from JSPS KAKENHI (Grant number JP22K16155).
Data Availability
The authors declare that the data supporting the findings of this study are available from the corresponding author upon reasonable request.
REFERENCES
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1 Whitlock RP, Belley-Cote EP, Paparella D, Healey JS, Brady K, Sharma M et al. Left Atrial appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med. 2021;384:2081-91. doi:10.1056/NEJMoa2101897.
» https://doi.org/10.1056/NEJMoa2101897. -
2 Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149:e1-e156. doi:10.1161/CIR.0000000000001193. Erratum in: Circulation. 2024;149(1):e167. doi:10.1161/CIR.0000000000001207. Erratum in: Circulation. 2024;149(9):e936. doi:10.1161/CIR.0000000000001218. Erratum in: Circulation. 2024;149(24):e1413. doi: 10.1161/CIR.0000000000001263.
» https://doi.org/10.1161/CIR.0000000000001193. -
3 Baudo M, Sicouri S, Yamashita M, Senzai M, McCarthy PM, Gerdisch MW, et al. Stroke prevention with prophylactic left atrial appendage occlusion in cardiac surgery patients without atrial fibrillation: a meta-analysis of randomized and propensity-score studies. Circ Cardiovasc Interv. 2024;17:e014296. doi:10.1161/CIRCINTERVENTIONS.124.014296.
» https://doi.org/10.1161/CIRCINTERVENTIONS.124.014296. -
4 Yasuda S, Nakao K, Nishimura K, Miyamoto Y, Sumita Y, Shishido T, et al. The Current status of cardiovascular medicine in Japan - analysis of a large number of health records from a nationwide claim-based database, JROAD-DPC. Circ J. 2016;80:2327-35. doi:10.1253/circj.CJ-16-0196
» https://doi.org/10.1253/circj.CJ-16-0196
Edited by
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Editor-in-chief:
Henrique Murad https://orcid.org/0000-0002-9543-7832
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Associate Editor:
Luiz Fernando Kubrusly https://orcid.org/0000-0002-6546-9841
