Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery
Abstract
Background:
The objective of this study was to evaluate the impact of left atrial appendage (LAA) exclusion on short-term outcomes in patients with atrial fibrillation undergoing isolated coronary artery bypass graft surgery.
Methods:
We queried the 2010 to 2014 National Readmissions Database for patients who underwent coronary artery bypass graft repair with and without LAA ligation by using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification: 36.1xx). Only patients with a history of atrial fibrillation were included in our analysis. The primary outcome of our study was 30-day readmissions following discharge. Secondary outcomes were in-hospital mortality and stroke. To assess the postoperative outcomes, we used multivariate logistic regression models to adjust for clinical and demographic covariates.
Results:
In total, we analyzed 253 287 patients undergoing coronary artery bypass graft surgery, 7.0% of whom received LAA closure. LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P<0.0001) and acute kidney injury (21.8% versus 18.5%, P<0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with a nonsignificant reduction in stroke (7.9% versus 8.6%, P=0.12), no difference in in-hospital mortality (2.2% versus 2.2% P=0.99), and a greater risk of 30-day readmission (16.0% versus 9.6%, P<0.0001). After covariate adjustment, LAA ligation remained a significant predictor of 30-day readmission (odds ratio, 1.640 [95% CI, 1.603–1.677], P<0.0001).
Conclusions:
LAA exclusion during isolated coronary artery bypass graft surgery in patients with atrial fibrillation is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.
Clinical Perspective
What Is New?
•
Left atrial appendage exclusion performed during isolated coronary artery bypass graft surgery in patients with atrial fibrillation was shown to significantly increase the risk of 30-day readmission along with an increased risk of respiratory failure and acute kidney injury, postoperatively.
•
Left atrial appendage exclusion was shown to significantly reduce 30-day readmissions for strokes.
What Are the Clinical Implications?
•
These findings highlight the need for further research to not only understand but also to manage this increased risk of 30-day readmission after left atrial appendage exclusion.
Introduction
Atrial fibrillation (AF) is the most commonly seen arrhythmia and affects 33.5 million individuals worldwide and 5 million in the United States alone,1 and it accounts for ≈20% of all ischemic strokes.2 Chronic AF is associated with dilation and loss of contractile function of the left atrium with subsequent stasis in the left atrial appendage (LAA) with the risk of thrombus formation and embolic stroke. The LAA has been implicated as the source of the embolism in >90% of cases of stroke in which the thrombus could be identified.3 Surgical exclusion of the LAA is often performed as an adjunct procedure during cardiac surgery for thromboembolic prophylaxis in patients with AF.4
Although surgical LAA exclusion was first proposed more than half a century ago as a method of thromboembolic prophylaxis, there remain limited data on the effectiveness of LAA exclusion to guide evidence-based decision making.5
Current guidelines recommend that, at the time of concomitant cardiac operations in patients with AF, it is reasonable to surgically manage the LAA for a presumed longitudinal benefit of thromboembolic morbidity prevention; its impact on short-term morbidity and mortality has not been systematically investigated.6 Thus, the objective of this study was to evaluate the impact of LAA exclusion on short-term outcomes in patients with AF undergoing isolated coronary artery bypass graft (CABG) surgery through a retrospective population-based cohort study of the 2010 to 2014 US National Readmissions Database.
Methods
Data Source
The National Readmissions Database (NRD) is drawn from the Healthcare Utilization Project State Inpatient Databases and was created to address the lack of nationally representative information on hospital readmissions for all patients in the United States.7 In the NRD, all patients with ≥1 inpatient hospitalizations are assigned a verified deidentified patient linkage number allowing tracking of discharges for an individual across hospitals within a state throughout a calendar year. The NRD can be weighted to generate national estimates of hospital admissions in the United States. The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.
Study Design and Cohort Definition
The cohort included adult patients who underwent isolated CABG surgery between January 1, 2010, and December 31, 2014 using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for CABG (ICD-9-CM 36.1). Only patients with a history of AF were further included in analysis by using ICD-9-CM 427.31, as has been previously published.8,9 Patients undergoing concomitant aortic valve surgery (ICD-9-CM 35.11, 35.21, or 35.22), tricuspid valve surgery (ICD-9-CM 35.14, 35.27, or 35.28), or mitral valve surgery (ICD-9-CM 35.12, 35.23, or 35.24) were excluded from analysis.
For analysis of readmission, only patients who were discharged alive during their initial hospitalization were included in the study, because they were the only population at risk of readmissions. Initial hospitalizations were from January to November to allow for 30-day follow-up in the NRD. Last, patients who were missing either length of stay or NRD_DaysToEvent were excluded, because it is impossible to determine the number of days until a subsequent readmission without this information.
Exposure
LAA occlusion was identified by using ICD-9-CM procedure code 37.36.
Assessment of Primary and Secondary Outcome
The primary outcome was inpatient rehospitalization within 30 days. Secondary outcomes included acute ischemic stroke or systemic embolism (hereafter referred to as stroke) and in-hospital mortality. Stroke included transient ischemic attacks (Clinical Classification Software code 122 or acute stroke [Clinical Classification Software code 109]).
Statistical Analysis
We used discharge weights provided in the NRD database to obtain national-level estimates of readmissions using both patient and hospital characteristics. Categorical variables are presented as proportions and compared by using a χ2 test. Continuous variables are presented as means and 95% CIs. Unadjusted outcome proportions were calculated for black versus white patients, with a corresponding P value from a χ2 test. For the adjusted analysis, we inserted potential confounders of the association of cardiovascular risk with readmission into a logistic regression model. Confounder selection was based on well-established cardiovascular risk factors, including patient demographic factors, comorbidities, hospital presentation variables, and surgical covariates. The data are presented as odds ratios and 95% CIs. All tests were 2-sided. All patient-level analyses were performed in accordance with survey methodology recommended by the Healthcare Cost and Utilization Project and conducted using SAS version 9.4 (SAS Institute Inc).
Results
Patient Characteristics
A total of 816 605 patients underwent CABG surgery between January 1, 2010, and December 31, 2014. After the application of exclusion criteria (Figure 1), 253 287 patients were included in our study, of whom 226 856 had 30-day follow-up. In our overall cohort, 22 755 (10.6%) of patients were readmitted within 30 days. Table 1 demonstrates the clinical and demographic data for patients by their readmission status. Readmitted patients were more commonly older, were obese, had nonelective admission, and had a higher rate of cardiovascular risk factors such as diabetes mellitus, heart failure, and peripheral vascular disease (Table 1).
| Characteristic | No 30-Day Readmission(n=204 101) | 30-Day Readmission(n=22 755) | P Value |
|---|---|---|---|
| Clinical and demographic | |||
| Age | |||
| <50 | 4883 (2.4) | 306 (1.3) | <0.0001 |
| 50–64 | 56 005 (27.4) | 4821 (21.2) | <0.0001 |
| 65–74 | 81 080 (39.7) | 8558 (37.6) | <0.0001 |
| 75–84 | 55 751 (27.3) | 7925 (34.8) | <0.0001 |
| >84 | 6382 (3.2) | 1145 (5.0) | <0.0001 |
| Female | 47 380 (23.2) | 6699 (29.4) | <0.0001 |
| Insurance status | |||
| Medicare | 135 463 (66.6) | 17 203 (75.8) | <0.0001 |
| Medicaid | 8178 (4) | 972 (4.3) | <0.0001 |
| Private insurance | 49004 (24.1) | 3755 (16.5) | <0.0001 |
| Other | 10 879 (5.3) | 775 (3.4) | <0.0001 |
| Median household income by zip code | |||
| 0–25th percentile | 54 045 (26.9) | 6195 (27.6) | <0.0001 |
| 26th to 50th percentile (median) | 54 914 (27.4) | 6068 (27.1) | <0.0001 |
| 51st to 75th percentile | 49 330 (24.6) | 5502 (24.5) | <0.0001 |
| 76th to 100th percentile | 42 333 (21.1) | 4651 (20.8) | |
| Obesity | 45 435 (22.3) | 5670 (24.9) | <0.0001 |
| Smoking | 82 050 (40.2) | 8377 (36.8) | <0.0001 |
| Hypertension (combine uncomplicated and complicated) | 166 191 (81.4) | 18 687 (82.1) | 0.1773 |
| History of percutaneous coronary intervention | 33 025 (16.2) | 3586 (15.8) | 0.3757 |
| History of myocardial infarction | 32 171 (15.8) | 3785 (16.6) | 0.0798 |
| History of TIA/stroke | 13 958 (6.8) | 1863 (8.2) | <0.0001 |
| Family history of coronary artery disease | 22 923 (11.2) | 1843 (8.1) | <0.0001 |
| Congestive heart failure | 4790 (2.3) | 884 (3.9) | <0.0001 |
| Diabetes mellitus, uncomplicated | 70 401 (34.5) | 8117 (35.7) | 0.0642 |
| Diabetes mellitus with chronic complications | 16 951 (8.3) | 2644 (11.6) | <0.0001 |
| Other neurological disorders | 8639 (4.2) | 1267 (5.6) | <0.0001 |
| Peripheral vascular disorders | 34 459 (16.9) | 4757 (20.9) | <0.0001 |
| Valvular disease | 1568 (0.8) | 297 (1.3) | <0.0001 |
| Chronic obstructive pulmonary disease | 46 767 (22.9) | 6666 (29.3) | <0.0001 |
| Chronic renal failure | 4481 (2.2) | 833 (3.7) | <0.0001 |
| Hospital size | |||
| Small | 12 857 (6.3) | 1321 (5.8) | 0.2057 |
| Medium | 35 533 (17.4) | 3857 (16.9) | 0.2057 |
| Large | 155 711 (76.3) | 17 577 (77.2) | 0.2057 |
| Metropolitan teaching | 128 285 (62.9) | 14 258 (62.7) | 0.9587 |
| Nonmetropolitan hospital | 6782 (3.3) | 758 (3.3) | 0.9587 |
| Hospital course | |||
| Elective admission | 94 978 (46.6) | 9445 (41.5) | <0.0001 |
| Acute myocardial infarction | 63 674 (31.2) | 7548 (33.2) | 0.0023 |
| ST-segment–elevation myocardial infarction | 13 876 (6.8) | 1386 (6.1) | 0.0319 |
| Acute coronary syndromes without ST-segment elevation | 96 904 (47.5) | 10 949 (48.1) | 0.3301 |
| Intra-aortic balloon pump | 18 499 (9.1) | 2198 (9.7) | 0.1122 |
| Percutaneous ventricular assist devices | 155 (0.1) | 32 (0.1) | 0.1560 |
| Left atrial appendage closure | 13 292 (6.5) | 2530 (11.1) | <0.0001 |
| Surgical ablation of atrial fibrillation | 9978 (4.9) | 1937 (8.5) | <0.0001 |
| Blood transfusion | 77 334 (37.9) | 8970 (39.4) | 0.0167 |
| Postoperative respiratory failure | 11 550 (5.7) | 1700 (7.5) | <0.0001 |
| Acute kidney injury | 34 322 (16.8) | 5615 (24.7) | <0.0001 |
| Cardiac tamponade | 1202 (0.6) | 144 (0.6) | 0.6629 |
| Acute stroke | 15 603 (7.6) | 2378 (10.4) | <0.0001 |
| Routine discharge | 76 025 (37.2) | 6005 (26.4) | <0.0001 |
Data are presented as n (%). TIA indicates transient ischemic attack.
The clinical course of hospital readmissions is described in Table 2. Only 7.6% of hospital readmissions were elective, 13% of patients who were readmitted had respiratory failure, 5.2% of readmitted patients had an acute stroke, and 1.9% underwent pericardiotomy. Hospital readmissions were associated with an in-hospital mortality of 3%.
| Outcomes | 30-Day Readmission (n=22 755) |
|---|---|
| Elective admission | 1723 (7.6) |
| Severe sepsis or septic shock | 727 (3.2) |
| Cardiogenic shock | 237 (1) |
| Inotrope use | 196 (0.9) |
| Mechanical ventilation | 1471 (6.5) |
| Cardiac tamponade | 370 (1.6) |
| Pericardiotomy | 428 (1.9) |
| Respiratory failure | 2956 (13) |
| Surgery of the chest | 5787 (25.4) |
| In-hospital mortality | 680 (3) |
| Noninvasive mechanical ventilation | 799 (3.5) |
| Acute stroke | 1187 (5.2) |
Data are presented as n (%).
Association of LAA Closure and Surgical Outcomes
Overall, 17 763 (7.0%) patients underwent LAA exclusion, and its use steadily increased during our 4-year study period (Figure 2). Patients who underwent LAA exclusion were more commonly older patients who had a history of cerebrovascular accidents (Table 3). LAA exclusion was less commonly performed in ST-segment–elevation myocardial infarction admissions (4% versus 7.3%, P<0.0001), and patients undergoing LAA exclusion were more likely to receive concomitant AF ablation surgery (21.9% versus 4.0%, P<0.0001). There were no significant differences in the prevalence of comorbidities such as history of congestive heart failure, diabetes mellitus, obesity, chronic obstructive pulmonary disease, or renal failure between patients who received LAA occlusion and those who did not.
| Characteristic | LAA Exclusion(n=17 763) | No LAA Exclusion (n=235 524) | P Value |
|---|---|---|---|
| Clinical and demographic | |||
| Age | |||
| <50 | 296 (1.7) | 5424 (2.3) | <0.0001 |
| 50–64 | 4006 (22.6) | 63 329 (26.9) | <0.0001 |
| 65–74 | 7252 (40.8) | 92 316 (39.2) | <0.0001 |
| 75–84 | 5646 (31.8) | 66 234 (28.1) | <0.0001 |
| >84 | 562 (3.2) | 8221 (3.5) | <0.0001 |
| Female | 3932 (22.1) | 56 980 (24.2) | 0.0089 |
| Insurance status | |||
| Medicare | 12 890 (72.6) | 158 420 (67.5) | <0.0001 |
| Medicaid | 502 (2.8) | 9659 (4.1) | <0.0001 |
| Private insurance | 3621 (20.4) | 54 538 (23.2) | <0.0001 |
| Other | 733 (4.1) | 12 219 (5.2) | <0.0001 |
| Median household income by zip code | |||
| 0–25th percentile | 4065 (23.2) | 63 332 (27.4) | <0.0001 |
| 26th to 50th percentile (median) | 5150 (29.4) | 62 977 (27.2) | <0.0001 |
| 51st to 75th percentile | 4452 (25.4) | 56 854 (24.6) | <0.0001 |
| 76th to 100th percentile | 3855 (22) | 48 286 (20.9) | <0.0001 |
| Obesity | 4193 (23.6) | 52 878 (22.5) | 0.0704 |
| Smoking | 6687 (37.6) | 93 510 (39.7) | 0.0209 |
| Hypertension (combine uncomplicated and complicated) | 14 292 (80.5) | 191 915 (81.5) | 0.1259 |
| History of percutaneous coronary intervention | 2584 (14.5) | 38 113 (16.2) | 0.0048 |
| History of myocardial infarction | 2650 (14.9) | 37 191 (15.8) | 0.1790 |
| History of TIA/stroke | 1527 (8.6) | 16 228 (6.9) | <0.0001 |
| Family history of coronary artery disease | 1657 (9.3) | 25 622 (10.9) | 0.0050 |
| Congestive heart failure | 555 (3.1) | 6393 (2.7) | 0.0975 |
| Diabetes mellitus, uncomplicated | 5959 (33.5) | 81 591 (34.6) | 0.1763 |
| Diabetes mellitus with chronic complications | 1484 (8.4) | 20 689 (8.8) | 0.3015 |
| Other neurological disorders | 704 (4) | 10 666 (4.5) | 0.0617 |
| Peripheral vascular disorders | 2864 (16.1) | 41 700 (17.7) | 0.0062 |
| Valvular disease | 247 (1.4) | 2028 (0.9) | 0.0010 |
| Chronic obstructive pulmonary disease | 4062 (22.9) | 55 892 (23.7) | 0.2155 |
| Chronic renal failure | 428 (2.4) | 5655 (2.4) | 0.9740 |
| Hospital size | |||
| Small | 1491 (8.4) | 14 252 (6.1) | 0.0070 |
| Medium | 3118 (17.6) | 40 895 (17.4) | 0.0070 |
| Large | 13 154 (74.1) | 180 377 (76.6) | 0.0070 |
| Metropolitan teaching | 11 710 (65.9) | 147 389 (62.6) | <0.0001 |
| Nonmetropolitan hospital | 264 (1.5) | 8210 (3.5) | <0.0001 |
| Hospital course | |||
| Elective admission | 9282 (52.3) | 106 139 (45.1) | <0.0001 |
| Acute myocardial infarction | 4531 (25.5) | 76 643 (32.5) | <0.0001 |
| ST-segment–elevation myocardial infarction | 703 (4) | 17 115 (7.3) | <0.0001 |
| Acute coronary syndromes without ST-segment elevation | 6832 (38.5) | 113 999 (48.4) | <0.0001 |
| Intra-aortic balloon pump | 1346 (7.6) | 23 700 (10.1) | <0.0001 |
| Percutaneous ventricular assist devices | 25 (0.1) | 316 (0.1) | 0.9097 |
| Surgical ablation of atrial fibrillation | 3895 (21.9) | 9495 (4.0) | <0.0001 |
| Blood transfusion | 6772 (38.1) | 89 875 (38.2) | 0.9761 |
| Postoperative respiratory failure | 1452 (8.2) | 14 668 (6.2) | <0.0001 |
| Acute kidney injury | 3867 (21.8) | 43 565 (18.5) | <0.0001 |
| Cardiac tamponade | 117 (0.7) | 1573 (0.7) | 0.9165 |
| Acute stroke | 1407 (7.9) | 20 254 (8.6) | 0.1232 |
| Routine discharge | 5848 (32.9) | 83 443 (35.4) | 0.0137 |
| In-hospital mortality | 387 (2.2) | 5129 (2.2) | 0.99 |
Data are presented as n (%). LAA indicates left atrial appendage; and TIA, transient ischemic attack
LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P<0.0001) and acute kidney injury (21.8% versus 18.5%, P<0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with no difference in in-hospital mortality (2.2% versus 2.2% P=0.99) and a greater risk of 30-day readmission (16.0% versus 9.6%, P<0.0001; Figure 3). No significant difference in in-hospital stroke was observed with LAA exclusion (8.6% versus 7.9%, P=0.12), but we did find a statistically significant reduction in 30-day readmission for stroke in patients undergoing LAA exclusion (0.4% versus 1.1%, P=0.04).
Multivariate Predictors of Hospital Readmission
Multivariable logistic regression analysis for 30-day readmission is described in Table 4. LAA closure remained a significant predictor of 30-day readmission (odds ratio, 1.64 [95% CI, 1.60–1.68], P<0.0001) after multivariate adjustment of patient characteristics (age, sex, diabetes mellitus status, obesity, heart failure, renal disease, and income) and admission characteristics (elective status, ST-segment–elevation myocardial infarction, surgical ablation of AF).
| Characteristics | Point Estimate | 95% Confidence Interval | P Value | |
|---|---|---|---|---|
| Age | ||||
| <50 | Ref | Ref | Ref | |
| 50–64 | 1.377 | 1.305 | 1.452 | <0.0001 |
| 65–74 | 1.643 | 1.558 | 1.732 | <0.0001 |
| 75–84 | 2.191 | 2.077 | 2.311 | <0.0001 |
| >84 | 2.825 | 2.660 | 3.001 | <0.0001 |
| Congestive heart failure | 1.397 | 1.354 | 1.442 | <0.0001 |
| Obesity | 1.234 | 1.214 | 1.254 | <0.0001 |
| Left atrial appendage exclusion | 1.640 | 1.603 | 1.677 | <0.0001 |
| Female | 1.256 | 1.237 | 1.276 | <0.0001 |
| Diabetes mellitus | 1.053 | 1.039 | 1.068 | 0.0698 |
| Smoking | 0.938 | 0.925 | 0.950 | 0.0108 |
| Acute myocardial infarction | 1.083 | 1.067 | 1.098 | 0.0179 |
| Neurological deficit | 1.260 | 1.226 | 1.295 | 0.0001 |
| Peripheral vascular disease | 1.248 | 1.228 | 1.268 | <0.0001 |
| Chronic renal failure | 1.685 | 1.616 | 1.756 | <0.0001 |
| Year* | 0.981 | 0.976 | 0.986 | 0.0268 |
| Surgical ablation of atrial fibrillation | 1.610 | 1.563 | 1.658 | <0.0001 |
*
Year represents the increasing use of left atrial appendage closure and improvement in 30-day readmissions during our study period.
Discussion
Current guidelines suggest that it is reasonable to perform LAA exclusion at the time of cardiac surgery for patients with AF given the risk of thromboembolic events originating from the LAA.6 In this study, we demonstrate that, although LAA exclusion is increasingly being performed in the United States during isolated CABG surgery, it is associated with a greater risk of 30-day readmissions, and postprocedural complications, as well, such as respiratory failure and acute kidney injury. Furthermore, we demonstrate that hospital readmissions impart a greater risk of mortality than the initial admission. Consistent with previous analysis, our study demonstrates that LAA exclusion is not associated with a significant reduction in in-hospital stroke risk following surgery; however, with a longer follow-up not available in previous literature, we demonstrate that 30-day readmission for strokes is significantly reduced for patients who undergo LAA exclusion. Thus, our study highlights the need for further research to understand and manage the increased risk of readmission following LAA exclusion in these patients.
The LAA has reservoir, contractile and endocrine functions.10 The reservoir and contractile functions serve to increase the left atrial stroke volume.11 In addition, the release to atrial natriuretic peptide by the LAA increases urine output in response to fluid overload.12,13 Both of these functions could be potentially protective against fluid overload and heart failure. Our analysis also demonstrates that hospitalizations that occurred within 30 days of the surgical admission were associated not only with a greater burden of mortality than the initial hospitalization, but were often related to respiratory failure and admissions requiring pericardiotomy. Although a definitive cause-and-effect relationship cannot be established, it is plausible that surgical exclusion mitigates the beneficial hormonal and hemodynamic role of the LAA, carrying an additional risk of fluid overload. Thus, our study suggests that patients undergoing LAA exclusion may require judicious use of diuretic agents after LAA exclusion to restore homeostasis following the loss of atrial natriuretic peptide preventing volume overload.
Loss of left atrial contractile function in chronic AF with consequent stasis results in thrombus formation within the LAA that accounts for 25% of all strokes.3,13,14 Because left atriotomy is performed as part of the procedure, it is recommended to perform concomitant LAA occlusion in patients with AF undergoing mitral valve surgery. However, in isolated CABG surgery, besides prolonging the cross clamp and cardiopulmonary bypass duration, surgical exclusion of the LAA involves the added step of left atriotomy, with the additional risk of incomplete surgical closure, bleeding complications, and cardiac injury. Thus, the performance of LAA exclusion as a concomitant procedure during isolated CABG surgery remains controversial. Current studies have also shown a mixed association of LAA exclusion with in-hospital mortality and postsurgical outcomes, including stroke.15–20 Our study demonstrates that LAA exclusion is not associated with a significant reduction in stroke risk following surgery. Because flush exclusion of LAA without a residual stump has to be balanced with the risk of coronary vascular injury, we hypothesize that this may be secondary to incomplete closure of the LAA, which occurs in 10% to 80% of surgeries,21 and quite possibly could increase the risk of stasis and thrombus formation in the residual stump of the LAA.22,23
Although our study is from the largest available data collection in the United States for hospital readmissions, it is inherently subjected to the limitations of an administrative data set. In particular, there is no information on laboratory data, anticoagulation status, method for LAA exclusion, severity of AF, or operative information. The prevalence of AF is likely overestimated in this population through the inclusion of patients with postoperative AF, which would dilute the strength of our findings. Moreover, although our study raises questions about the safety and short-term outcome impact of LAA exclusion as a concomitant procedure during isolated CABG surgery, the therapeutic value of LAA exclusion could not be assessed in this study given the short window of follow-up. Whether a long-term benefit outweighs the short-term risk of complications after LAA exclusion in CABG surgery will be more definitively established in a randomized control trial through the ongoing LAAOS III study (Left Atrial Appendage Occlusion Study III).24
Conclusions
In a large retrospective cohort review of patients with AF undergoing isolated CABG surgery in the United States, we demonstrate that LAA exclusion is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.
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Received: 29 October 2019
Accepted: 24 April 2020
Published online: 3 June 2020
Published in print: 7 July 2020
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