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 R. Holmes, Jonathan P. Piccini, Rakesh M. Suri, Michael J. Mack, Vinay Badhwar, Jeffrey P. Jacobs, Eric D. Peterson, Shein Chung Chow, J. Matthew Brennan*

*Corresponding author for this work

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 CHA 2 DS 2 -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 (p trend < 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 CHA 2 DS 2 -VASc score-defined stroke risk).

Original languageEnglish (US)
JournalJournal of Interventional Cardiac Electrophysiology
DOIs
StatePublished - 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

Friedman, Daniel J. ; Gaca, Jeffrey G. ; Wang, Tongrong ; Malaisrie, S Chris ; Holmes, David R. ; 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.
@article{056ed77833e94e38b2c85a80b7777e7c,
title = "Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation: a national cohort study",
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 CHA 2 DS 2 -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 (p trend < 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 CHA 2 DS 2 -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 Holmes, {David R.} 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.",
year = "2019",
month = "1",
day = "1",
doi = "10.1007/s10840-019-00519-w",
language = "English (US)",
journal = "Journal of Interventional Cardiac Electrophysiology",
issn = "1383-875X",
publisher = "Springer Netherlands",

}

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 R.; 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

TY - JOUR

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 R.

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 CHA 2 DS 2 -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 (p trend < 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 CHA 2 DS 2 -VASc score-defined stroke risk).

AB - 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 CHA 2 DS 2 -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 (p trend < 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 CHA 2 DS 2 -VASc score-defined stroke risk).

KW - Arrhythmia therapy (including ablation

KW - Atrial fibrillation

KW - Atrial flutter

KW - Drugs)

KW - Surgery

UR - http://www.scopus.com/inward/record.url?scp=85061051175&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85061051175&partnerID=8YFLogxK

U2 - 10.1007/s10840-019-00519-w

DO - 10.1007/s10840-019-00519-w

M3 - Article

JO - Journal of Interventional Cardiac Electrophysiology

JF - Journal of Interventional Cardiac Electrophysiology

SN - 1383-875X

ER -