Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: the LAACS randomized study

• DOI: 10.1186/s13019-018-0740-7
• Publication Date: 2018-05-23T07:38:04Z
• Authors: Jesper Park-Hansen; Susanne J.V. Holme; Akhmadjon Irmukha...; Christian L. Carr...; Anders M. Greve; Gina Al-Farra; Robert G. C. Riis; Brian Nilsson; Johan S.R. Clausen; Anne S. Nørskov; Christina R. Kruuse; Egill Rostrup; Helena Dominguez
• Keywords: Male; RD1-811; Denmark; Postoperative Complications/diagnostic imaging; Cardiac Surgical Procedures/methods; Disease-Free Survival; Brain Ischemia; Prosthesis Implantation; 03 medical and health sciences; Postoperative Complications; 0302 clinical medicine; Anesthesiology; Brain Ischemia/diagnostic imaging; Atrial Fibrillation; Humans; RD78.3-87.3; Atrial Appendage; Prospective Studies; Cardiac Surgical Procedures; Atrial Appendage/surgery; Aged; Anticoagulants; Left atrial appendage closure; Atrial fibrillation; Magnetic Resonance Imaging; Heart surgery; 3. Good health; Stroke; Treatment Outcome; Anticoagulants/therapeutic use; Surgery; Female; Research Article

Open heart surgery is associated with high occurrence of atrial fibrillation (AF), subsequently increasing the risk of post-operative ischemic stroke. Concomitant with open heart surgery, a cardiac ablation procedure is commonly performed in patients with known AF, often followed by left atrial appendage closure with surgery (LAACS). However, the protective effect of LAACS on the risk of cerebral ischemia following cardiac surgery remains controversial. We have studied whether LAACS in addition to open heart surgery protects against post-operative ischemic brain injury regardless of a previous AF diagnosis.One hundred eighty-seven patients scheduled for open heart surgery were enrolled in a prospective, open-label clinical trial and randomized to concomitant LAACS vs. standard care. Randomization was stratified by usage of oral anticoagulation (OAC) planned to last at least 3 months after surgery. The primary endpoint was a composite of post-operative symptomatic ischemic stroke, transient ischemic attack or imaging findings of silent cerebral ischemic (SCI) lesions.During a mean follow-up of 3.7 years, 14 (16%) primary events occurred among patients receiving standard surgery vs. 5 (5%) in the group randomized to additional LAACS (hazard ratio 0.3; 95% CI: 0.1-0.8, p = 0.02). In per protocol analysis (n = 141), 14 (18%) primary events occurred in the control group vs. 4 (6%) in the LAACS group (hazard ratio 0.3; 95% CI: 0.1-1.0, p = 0.05).In a real-world setting, LAACS in addition to elective open-heart surgery was associated with lower risk of post-operative ischemic brain injury. The protective effect was not conditional on AF/OAC status at baseline.LAACS study, clinicaltrials.gov NCT02378116 , March 4th 2015, retrospectively registered.