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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Early Discontinuation of Long-Term Anticoagulation After Surgical Left Atrial Appendage Occlusion
Nicholas J Goel1, Yu Zhao2, Alexandra E Sperry3
1Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (CAVOQER), Philadelphia, Pennsylvania.
Insights
Discontinuing anticoagulation after surgical left atrial appendage occlusion (sLAAO) in atrial fibrillation (AF) patients did not increase composite risk for mortality, embolism, or bleeding over five years. These findings suggest safe anticoagulation discontinuation post-sLAAO for select AF patients.
Area of Science:
- Cardiology
- Vascular Surgery
- Medical Informatics
Background:
- Surgical left atrial appendage occlusion (sLAAO) is a stroke prevention strategy for atrial fibrillation (AF) patients.
- The safety of discontinuing long-term anticoagulation (AC) after sLAAO in AF patients remains unclear.
Purpose of the Study:
- To evaluate the safety and outcomes of discontinuing anticoagulation (AC) after surgical left atrial appendage occlusion (sLAAO) in patients with atrial fibrillation (AF).
- To compare the composite risk of mortality, embolism, and major bleeding between AF patients who discontinued AC versus those who continued AC after sLAAO.
Main Methods:
- A retrospective study of Medicare patients with AF undergoing cardiac surgery (CABG or valve surgery) from 2016-2019.
- Propensity score matching was used to compare patients who discontinued AC within 90 days post-sLAAO versus those who continued AC.
- Outcomes assessed included embolic events, major bleeding, and a composite of mortality, embolism, or major bleeding over five years.
Main Results:
- Among 10,407 sLAAO patients, 14.0% discontinued AC early. Early discontinuation was associated with a 1% higher risk of embolic events (6.3% vs 5.3%).
- However, early AC discontinuation significantly reduced the risk of major bleeding (13.4% vs 17.8%).
- No significant difference was observed in the composite outcome of mortality, embolism, or major bleeding between early discontinuation and continued AC groups (34.0% vs 34.0%).
Conclusions:
- AF patients undergoing sLAAO who discontinued long-term AC did not experience an increased five-year composite risk of mortality, embolism, or major bleeding.
- Discontinuation of AC after sLAAO may be a safe option with acceptable long-term outcomes for many AF patients.
Background:
Surgical left atrial appendage occlusion (sLAAO) is known to prevent strokes in patients with atrial fibrillation (AF). However, for AF patients on long-term anticoagulation (AC), little is known about the safety of AC discontinuation after sLAAO.
Methods:
The study included Medicare patients with AF on AC undergoing coronary artery bypass grafting or valve surgery from 2016 to 2019. By propensity score matching, patients who did not continue AC more than 90 days after surgery were compared with patients continuing AC.
Results:
Of 10,407 patients undergoing sLAAO, 2470 (14.0%) exhibited early AC discontinuation and had 5-year risk of embolic events that was 1% higher (6.3% vs 5.3%; subdistribution hazard ratio [HR], 1.32 [1.05-1.59]; P = .043). However, the risk of major bleeding was much lower in those patients (13.7% vs 17.8%; subdistribution HR, 0.68 [0.57-0.82]; P < .001) such that no difference was observed in the composite outcome of mortality, embolism, or major bleeding (34.0% vs 34.0%; HR, 0.97 [0.86-1.10]; P = .64). Moreover, risk of embolism in sLAAO patients discontinuing AC was no different from that in AF patients continuing AC after surgery who did not undergo sLAAO (6.5% vs 6.5%; HR, 1.20 [0.93-1.47]; P = .18), and the risk of mortality, embolism, or major bleeding was lower (34.5% vs 38.6%; HR, 0.84 [0.74-0.95]; P = .006).
Conclusions:
AF patients on long-term AC who underwent sLAAO and discontinued AC after surgery were not at increased composite risk with respect to mortality, embolism, or major bleeding during 5 years. Discontinuation of long-term AC after sLAAO may be associated with acceptable long-term outcomes in many patients.
