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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Clinical Outcomes of Mortality, Readmissions, and Ischemic Stroke Among Medicare Patients Undergoing Left Atrial
Rajesh Kabra1, Saket Girotra2, Mary Vaughan Sarrazin2,3
1Division of Cardiology, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis.
Insights
Left atrial appendage closure (LAAC) in older adults with atrial fibrillation showed lower-than-expected ischemic stroke readmissions but higher 1-year mortality compared to trials, likely due to patient comorbidities and warfarin ineligibility.
Area of Science:
- Cardiology
- Medical Devices
- Public Health
Background:
- Left atrial appendage closure (LAAC) is a non-drug alternative for stroke prevention in nonvalvular atrial fibrillation.
- Limited contemporary data exist on patient characteristics and outcomes following LAAC procedures.
Purpose of the Study:
- To evaluate characteristics of Medicare beneficiaries undergoing LAAC.
- To assess postprocedural mortality, readmission rates, and ischemic stroke rates after LAAC.
Main Methods:
- Population-based cohort study using Medicare inpatient claims (2015-2017).
- Included 13,627 patients aged >65 with atrial fibrillation undergoing LAAC.
- Assessed mortality, 30-day readmissions, and 180-day ischemic stroke hospitalizations.
Main Results:
- Mean age was 78 years; 69% were >75 years old.
- 1-year mortality was 7.5%; 30-day readmission was 9.4%.
- 1.2% experienced readmission for ischemic stroke/TIA within 180 days.
Conclusions:
- LAAC in this older, comorbid population had lower-than-expected ischemic stroke readmissions.
- 1-year mortality was higher than in prior trials, potentially due to patient selection and warfarin ineligibility.
Importance:
Left atrial appendage closure (LAAC) has emerged as a nonpharmacological alternative for stroke prevention in patients with nonvalvular atrial fibrillation. Contemporary data regarding the characteristics and outcomes of patients undergoing this procedure are limited.
Objective:
To determine the characteristics, postprocedural mortality rate, and rates of readmission and ischemic stroke among Medicare beneficiaries who underwent LAAC via implanted device.
Design, Setting, And Participants:
This population-based cohort study used Medicare inpatient claims from January 2015 to December 2017 for 13 627 patients aged older than 65 years with a diagnosis of atrial fibrillation who underwent LAAC with an implanted device from January 2015 to November 2017. Data analyses were conducted from January through August 2019.
Exposure:
Left atrial appendage closure.
Main Outcomes And Measures:
Mortality rates during the index admission and for 1 year after LAAC were assessed. The 30-day readmission rate and the primary reasons for readmission were also examined. In addition, the likelihood of hospitalization for ischemic stroke within 180 days among 9231 patients for whom 6 months of follow-up data were available was evaluated.
Results:
Among the 13 627 patients undergoing LAAC, the mean (SD) age was 78.0 (6.3) years, 9406 (69.0%) were older than 75 years, 11 980 (87.9%) were white, and 5630 (41.3%) were women. The mean (SD) CHA2DS2-VASc score was 4.3 (1.4). Twenty-eight patients (0.2%) died during the index admission. Mortality rates were 0.6% (80 patients) at 30 days, 1.9% (262 patients) at 90 days, 4.0% (547 patients) at 180 days, and 7.5% (1027 patients) at 365 days. The 30-day readmission rate among 13 599 patients discharged alive was 9.4% (1284 patients). Among 9231 patients with 6 months of follow-up data, 111 (1.2%) experienced readmission for ischemic stroke or transient ischemic attack within 180 days of discharge.
Conclusions And Relevance:
In this cohort study of patients older than 65 years with atrial fibrillation who underwent LAAC with an implanted device, readmission rates for ischemic strokes over the course of 6 months were lower than expected given the patients' CHA2DS2-VASc scores in the absence of anticoagulation therapy. Mortality at 1 year was higher than that reported in previous randomized clinical trials, likely because the patients in the present study were older, had a higher number of comorbidities, and were ineligible to receive warfarin.
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