TOPLINE:

Left atrial appendage occlusion (LAAO) during cardiac surgery in patients with atrial fibrillation was associated with lower stroke-related disability and reduced risk for 30-day mortality and cardioembolic stroke than standard care, new research showed.

METHODOLOGY:

• Researchers conducted a post hoc exploratory analysis of the multinational LAAOS III randomized clinical trial and included more than 4800 participants (mean age, 71 years; 67.5% male; 80% receiving oral coagulation therapy). All had atrial fibrillation and a CHA₂DS₂-VASc score ≥ 2 and underwent cardiac surgery between 2012 and 2018.
• Participants were randomly assigned to receive either surgical LAAO plus standard care (LAAO group) or standard care alone (control group), with a mean follow-up of 3.8 years.
• The primary outcome was the occurrence of ischemic stroke or systemic embolism. Secondary outcomes included functional status, measured using modified Rankin Scale (mRS) scores on day 7 or at discharge, and 30-day mortality.

TAKEAWAY:

• About 273 participants had a first ischemic stroke during follow‑up. The LAAO group had a lower risk for first ischemic stroke than the control group (5% vs 7%, respectively; hazard ratio [HR], 0.66) and a lower proportion of ischemic strokes of presumed cardioembolic etiology than the control group (43% vs 58%; P = .01).
• Among those with first ischemic stroke, disability on day 7 or at discharge was lower in the LAAO group than in the control group (median mRS score, 2 vs 3, respectively; odds ratio [OR], 0.80). Cortical infarcts were also less frequent in the LAAO group (46% vs 61%; P = .01).
• About 19% of participants died within 30 days of their ischemic stroke event. Risk for 30‑day stroke mortality was lower in the LAAO group than in the control group (16.5% vs 20%; HR, 0.55).
• Time-to-event analysis also showed a lower risk for first cardioembolic stroke in the LAAO group (2% vs 4%; HR, 0.47). Sensitivity analysis confirmed the main findings, including lower disability (OR, 0.77) and lower 30-day mortality (14% vs 21%; HR, 0.45) in patients with vs without LAAO.

IN PRACTICE:

“Our findings support the recent guidelines from the American College of Cardiology/American Heart Association providing a strong recommendation for LAAO in patients with [atrial fibrillation] undergoing cardiac surgery, while providing a rationale for the inclusion of stroke severity as a secondary endpoint in ongoing clinical trials evaluating surgical or percutaneous LAAO for stroke prevention,” the investigators of the study wrote.

SOURCE:

The study was led by Aristeidis H. Katsanos, MD, PhD, Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada. It was published online on November 17 in JAMA Neurology.

LIMITATIONS:

Limited information was provided in clinical and radiologic reports for stroke adjudication. The approach used to classify stroke etiologies may have oversimplified the complex mechanisms of ischemic stroke by not accounting for features of small vessel disease or large artery involvement. The study did not systematically collect and analyze data on acute treatment and secondary stroke prevention strategies. The mRS scores were only available at 7 days or discharge, potentially influenced by in-hospital management, creating uncertainties related to the impacts of long-term disability.

DISCLOSURES:

LAAOS III was funded by the Canadian Institutes of Health Research, the Canadian Stroke Prevention Intervention Network, Hamilton Health Sciences Research Institute, the Heart and Stroke Foundation of Canada, the Request for Applications Program-Research Strategic Initiatives of Hamilton Health Sciences, the Canadian Network and Centre for Trials Internationally, and McMaster University Surgical Associates. Several investigators reported having financial ties with various organizations, including pharmaceutical companies. Full details are provided in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.