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©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
Surgical left atrial appendage occlusion during cardiac surgery: A systematic review and meta-analysis
Varunsiri Atti, Mahesh Anantha-Narayanan, Mohit K Turagam, Scott Koerber, Sunil Rao, Juan F Viles-Gonzalez, Rakesh M Suri, Poonam Velagapudi, Dhanunjaya Lakkireddy, David G Benditt
Varunsiri Atti, Department of Medicine, Michigan State University-Sparrow Hospital, East Lansing, MI 48912, United States
Mahesh Anantha-Narayanan, David G Benditt, Division of Cardiovascular diseases, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
Mohit K Turagam, Helmsley Electrophysiology Center, Icahn School of medicine at Mount Sinai, New York City, NY 10029, United States
Scott Koerber, Department of Cardiac Electrophysiology, Medical University of South Carolina, Charleston, SC 29425, United States
Sunil Rao, Department of Cardiovascular diseases, Genesys Heart Institute, Ascension Genesys Hospital, Grand Blanc, MI.
Juan F Viles-Gonzalez, Baptist Health South Florida, Professor of Medicine at Wertheim College of Medicine, Miami, FL 33176.
Rakesh M Suri, Cleveland Clinic Foundation and Cleveland Clinic Abu Dhabi, Department of Thoracic and Cardiovascular Surgery. Cleveland Clinic, Cleveland, OH 44195, United States
Poonam Velagapudi, Structural Heart and Valve Center, Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York City, NY 10027, United States
Dhanunjaya Lakkireddy, Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, MO 64132, United States
Supported by no external funding. Dr. Benditt is supported in part by a grant from the Dr. Earl E Bakken family in support of heart-brain research.
Author contributions: Atti V, Anantha-Narayanan M contributed equally to this work and performed the analysis. Turagam MK designed the research. Koerber S, Rao S, Viles-Gonzalez JF, Suri R, Velagapudi P, Lakkireddy D and Benditt DG supervised the research. All the authors had role in writing the manuscript.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author to: Mahesh Anantha-Narayanan, MD, Academic Fellow, Doctor, Division of Cardiovascular Diseases, Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, United States. manantha@umn.edu
Telephone: +1-612-6262451 Fax: +1-612-6264411
Received: August 9, 2018
Peer-review started: August 9, 2018
First decision: August 24, 2018
Revised: September 8, 2018
Accepted: October 12, 2018
Article in press: October 12, 2018
Published online: November 26, 2018
ARTICLE HIGHLIGHTS
Research background
The left atrial appendage (LAA) is a common site for intracardiac thrombus formation in patients with atrial fibrillation (AF). Surgical left atrial appendage occlusion (s-LAAO) during concomitant cardiac surgery has been evaluated as an effective treatment approach to reduce the risk of stroke and embolic events.
Research motivation
Percutaneous LAAO has been shown to be non-inferior compared with warfarin in reducing the risk of stroke and embolic events in two large randomized controlled trials, PROTECT-AF and PREVAIL. However, data regarding s-LAAO is conflicting and contrasting. So, we performed a systematic review and meta-analysis of all the studies published to date to evaluate if concomitant s-LAAO during cardiac surgery is safe and effective.
Research objectives
The purpose of this study is to evaluate the safety and efficacy of concomitant s-LAAO during cardiac surgery.
Research methods
We searched five databases for studies comparing concomitant s-LAAO with no occlusion during cardiac surgery. We obtained a total of 12 studies for inclusion and performed a meta-analysis. The outcomes of interest were embolic events, stroke, all-cause mortality, AF, postoperative complications and reoperation for bleeding.
Research results
Concomitant s-LAAO during cardiac surgery was associated with lower risk of embolic events and stroke. This was evident in the AF predominant strata as well. There was no significant difference in the risk of all-cause mortality, AF, postoperative complications and reoperation for bleeding.
Research conclusions
Our meta-analysis including all the studies published to date comparing concomitant s-LAAO against no occlusion during cardiac surgery supports the use of concomitant s-LAAO during cardiac surgeries. It was associated with lower risk of stroke and embolic events.
Research perspectives
From this meta-analysis, it could be seen that concomitant s-LAAO during cardiac surgeries was associated with lower risk of stroke and embolic events compared with no occlusion. This association was prominent amongst the AF predominant strata as well. These beneficial effects could be seen due to the occlusion of LAA which is the source of 90% thrombi in non-valvular AF. Future randomized trials are needed to evaluate the long term benefits of s-LAAO.
