Left atrial appendage exclusion during open cardiac surgery in patients without atrial fibrillation reduces 4-year ischemic stroke and mortality

Objective This study assessed the influence of surgical left atrial appendage exclusion (LAAE) during cardiac surgery in patients with no preoperative history of atrial fibrillation (AF). Methods Real World Data Insights, an all-payers’ claims database, with approximately 90% Medicare patients was utilized. Patients with no preoperative history of AF (older than age 65 years) undergoing open coronary artery bypass or valve procedures with/without concomitant surgical LAAE with an epicardial clip between 2015 and 2020 and a minimum of 2-year follow-up were included. Inverse probability treatment weighting and logistic regression were used. Results Open coronary artery bypass represented 48.8% (n = 29,954) and valve 51.2% (n = 31,466) of procedures after adjustment. Thirty-day postoperative AF was present in 12.2% patients (n = 175) for LAAE and 5.8% (n = 3485) for no-LAAE (P < .01). By day 90 after surgery, rates of new AF were similar between groups through 4-year follow-up. During 4 years of follow-up more patients received oral anticoagulation with LAAE (P < .01). LAAE had 28% lower adjusted ischemic stroke odds (odds ratio, 0.72; 95% CI, 0.53-0.98; P = .02) and 34% lower adjusted all-cause mortality (odds ratio, 0.66; 95% CI, 0.52-0.85; P < .01). In patients who developed postoperative AF, LAAE + oral anticoagulation showed 74% lower odds of adjusted ischemic stroke (odds ratio, 0.26; 95% CI, 0.10-0.70; P = .01) and 58% lower odds of adjusted all-cause mortality (odds ratio, 0.42; 95% CI, 0.18-1.01; P = .05) than no-LAAE + oral anticoagulation therapy alone. Conclusions LAAE during open cardiac surgery in patients without AF was safe, associated with higher postoperative AF, and lower ischemic stroke and all-cause mortality. Randomized controlled studies are ongoing in a similar population.