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Published on: February 26, 2013
Risk Stratification in Patients Who Underwent Percutaneous Left Atrial Appendage Occlusion
Matthew W Segar1, Allan Zhang2, Robert D Paisley1
1Department of Cardiology, Texas Heart Institute, Houston, Texas.
Insights
A recalibrated clinical risk score (CRS) improves early mortality prediction after Left Atrial Appendage Occlusion (LAAO). This enhanced risk stratification tool outperforms existing scores, aiding patient selection for LAAO procedures.
Area of Science:
- Cardiology
- Medical Devices
- Clinical Risk Stratification
Background:
- Left atrial appendage occlusion (LAAO) is a key strategy for preventing thromboembolism in patients with atrial fibrillation.
- Accurate risk stratification is crucial for identifying patients at high risk of early mortality post-LAAO.
- Existing risk scores may not optimally predict outcomes in the LAAO population.
Purpose of the Study:
- To validate and recalibrate a clinical risk score (CRS) for predicting all-cause mortality after LAAO.
- To compare the performance of the recalibrated CRS against established atrial fibrillation and generalized risk scores.
Main Methods:
- A single-center cohort of 223 patients undergoing LAAO was analyzed.
- A previously developed 5-variable CRS (age, BMI, diabetes, heart failure, eGFR) was applied and recalibrated.
- Cox proportional hazard models and Harrel C-index were used to assess mortality risk and discriminative ability.
Main Results:
- The 1- and 2-year mortality rates were 6.7% and 11.2%, respectively.
- Recalibration identified BMI <29 kg/m² and eGFR <60 mL/min/1.73 m² as significant predictors of mortality.
- The recalibrated CRS demonstrated improved discrimination (C-index 0.70) compared to the original CRS (0.65) and other scores (CHA2DS2-VASc=0.58, HAS-BLED=0.55, Walter index=0.62).
Conclusions:
- The recalibrated CRS accurately risk-stratifies patients undergoing LAAO.
- This improved risk score significantly outperforms established tools, offering better prediction of early mortality.
- Clinical risk scores, particularly the recalibrated CRS, should supplement standard evaluation for LAAO candidacy.
Abstract:
Left atrial appendage occlusion (LAAO) is effective in preventing thromboembolism. Risk stratification tools could help identify patients at risk for early mortality after LAAO. In this study, we validated and recalibrated a clinical risk score (CRS) to predict risk of all-cause mortality after LAAO. This study used data from patients who underwent LAAO in a single-center, tertiary hospital. A previously developed CRS using 5 variables (age, body mass index [BMI], diabetes, heart failure, and estimated glomerular filtration rate) was applied to each patient to assess risk of all-cause mortality at 1 and 2 years. The CRS was recalibrated to the present study cohort and compared with established atrial fibrillation-specific (CHA2DS2-VASc and HAS-BLED) and generalized (Walter index) risk scores. Cox proportional hazard models were used to assess the risk of mortality and discrimination was assessed by Harrel C-index. Among 223 patients, the 1- and 2-year mortality rates were 6.7% and 11.2%, respectively. With the original CRS, only low BMI (<23 kg/m2) was a significant predictor of all-cause mortality (hazard ratio [HR] [95% CI] 2.76 [1.03 to 7.35]; p = 0.04). With recalibration, BMI <29 kg/m2 and estimated glomerular filtration rate <60 ml/min/1.73 m2 were significantly associated with an increased risk of death (HR [95% CI] 3.24 [1.29 to 8.13] and 2.48 [1.07 to 5.74], respectively), with a trend toward significance noted for history of heart failure (HR [95% CI] 2.13 [0.97 to 4.67], p = 0.06). Recalibration improved the discriminative ability of the CRS from 0.65 to 0.70 and significantly outperformed established risk scores (CHA2DS2-VASc = 0.58, HAS-BLED = 0.55, Walter index = 0.62). In this single-center, observational study, the recalibrated CRS accurately risk stratified patients who underwent LAAO and significantly outperformed established atrial fibrillation-specific and generalized risk scores. In conclusion, clinical risk scores should be considered as an adjunct to standard of care when evaluating a patient's candidacy for LAAO.
