Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke

被引:477
作者
Whitlock, Richard P. [1 ,2 ,3 ]
Belley-Cote, Emilie P. [1 ,2 ,3 ]
Paparella, Domenico [8 ,9 ]
Healey, Jeff S. [1 ,2 ,3 ]
Brady, Katheryn [2 ,3 ]
Sharma, Mukul [1 ,2 ,3 ]
Reents, Wilko [11 ]
Budera, Petr [13 ]
Baddour, Andony J. [15 ]
Fila, Petr [14 ]
Devereaux, P. J. [1 ,2 ,3 ]
Bogachev-Prokophiev, Alexander [17 ]
Boening, Andreas [12 ]
Teoh, Kevin H. T. [4 ]
Tagarakis, Georgios I. [16 ]
Slaughter, Mark S. [18 ]
Royse, Alistair G. [19 ,20 ]
McGuinness, Shay [21 ]
Alings, Marco [22 ]
Punjabi, Prakash P. [24 ]
Mazer, C. David [5 ,6 ]
Folkeringa, Richard J. [23 ]
Colli, Andrea [10 ]
Avezum, Alvaro [25 ]
Nakamya, Juliet [1 ,3 ]
Balasubramanian, Kumar [1 ,3 ]
Vincent, Jessica [2 ,3 ]
Voisine, Pierre [7 ]
Lamy, Andre [1 ,2 ,3 ]
Yusuf, Salim [1 ,2 ,3 ]
Connolly, Stuart J. [1 ,2 ,3 ]
机构
[1] McMaster Univ, Hamilton, ON, Canada
[2] Hamilton Hlth Sci, Hamilton, ON, Canada
[3] Populat Hlth Res Inst, Hamilton, ON, Canada
[4] Southlake Reg Hlth Ctr, Newmarket, ON, Canada
[5] Univ Toronto, Toronto, ON, Canada
[6] St Michaels Hosp, Li Ka Shing Knowledge Inst, Toronto, ON, Canada
[7] Quebec Heart & Lung Inst, Quebec City, PQ, Canada
[8] Univ Foggia, Foggia, Italy
[9] Santa Maria Hosp, Grp Villa Maria Care & Res, Bari, Italy
[10] Univ Pisa, Pisa, Italy
[11] Rhon Klinikum Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
[12] Univ Hosp Giessen, Giessen, Germany
[13] Inst Clin & Expt Med, Prague, Czech Republic
[14] Ctr Cardiovasc Surg & Transplant, Brno, Czech Republic
[15] G Papanikolaou Hosp, Thessaloniki, Greece
[16] Aristotle Univ Thessaloniki, Thessaloniki, Greece
[17] E Meshalkin Natl Med Res Ctr, Novosibirsk, Russia
[18] Univ Louisville, Louisville, KY 40292 USA
[19] Univ Melbourne, Melbourne, Vic, Australia
[20] Royal Melbourne Hosp, Melbourne, Vic, Australia
[21] Auckland City Hosp, Auckland, New Zealand
[22] Amphia Ziekenhuis, Breda, Netherlands
[23] Med Ctr Leeuwarden, Leeuwarden, Netherlands
[24] Imperial Coll London, Natl Heart & Lung Inst, London, England
[25] Hosp Alemao Oswaldo Cruz, Int Res Ctr, Sao Paulo, Brazil
基金
加拿大健康研究院;
关键词
FIBRILLATION; METAANALYSIS;
D O I
10.1056/NEJMoa2101897
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
BACKGROUND Surgical occlusion of the left atrial appendage has been hypothesized to prevent ischemic stroke in patients with atrial fibrillation, but this has not been proved. The procedure can be performed during cardiac surgery undertaken for other reasons. METHODS We conducted a multicenter, randomized trial involving participants with atrial fibrillation and a CHA(2)DS(2)-VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating greater risk of stroke) who were scheduled to undergo cardiac surgery for another indication. The participants were randomly assigned to undergo or not undergo occlusion of the left atrial appendage during surgery; all the participants were expected to receive usual care, including oral anticoagulation, during follow-up. The primary outcome was the occurrence of ischemic stroke (including transient ischemic attack with positive neuroimaging) or systemic embolism. The participants, research personnel, and primary care physicians (other than the surgeons) were unaware of the trial-group assignments. RESULTS The primary analysis population included 2379 participants in the occlusion group and 2391 in the no-occlusion group, with a mean age of 71 years and a mean CHA(2)DS(2)-VASc score of 4.2. The participants were followed for a mean of 3.8 years. A total of 92.1% of the participants received the assigned procedure, and at 3 years, 76.8% of the participants continued to receive oral anticoagulation. Stroke or systemic embolism occurred in 114 participants (4.8%) in the occlusion group and in 168 (7.0%) in the no-occlusion group (hazard ratio, 0.67; 95% confidence interval, 0.53 to 0.85; P=0.001). The incidence of perioperative bleeding, heart failure, or death did not differ significantly between the trial groups. CONCLUSIONS Among participants with atrial fibrillation who had undergone cardiac surgery, most of whom continued to receive ongoing antithrombotic therapy, the risk of ischemic stroke or systemic embolism was lower with concomitant left atrial appendage occlusion performed during the surgery than without it.
引用
收藏
页码:2081 / 2091
页数:11
相关论文
共 17 条
[1]   Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation [J].
Blackshear, JL ;
Odell, JA .
ANNALS OF THORACIC SURGERY, 1996, 61 (02) :755-759
[2]   Definition and Evaluation of Transient Ischemic Attack A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. [J].
Easton, J. Donald ;
Saver, Jeffrey L. ;
Albers, Gregory W. ;
Alberts, Mark J. ;
Chaturvedi, Seemant ;
Feldmann, Edward ;
Hatsukami, Thomas S. ;
Higashida, Randall T. ;
Johnston, S. Claiborne ;
Kidwell, Chelsea S. ;
Lutsep, Helmi L. ;
Miller, Elaine ;
Sacco, Ralph L. .
STROKE, 2009, 40 (06) :2276-2293
[3]  
Fuster Valentin, 2006, Rev Esp Cardiol, V59, P1329
[4]   Selecting patients with atrial fibrillation for anticoagulation - Stroke risk stratification in patients taking aspirin [J].
Gage, BF ;
van Walraven, C ;
Pearce, L ;
Hart, RG ;
Koudstaal, PJ ;
Petersen, P .
CIRCULATION, 2004, 110 (16) :2287-2292
[5]   Prevalence of diagnosed atrial fibrillation in adults - National implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study [J].
Go, AS ;
Hylek, EM ;
Phillips, KA ;
Chang, YC ;
Henault, LE ;
Selby, JV ;
Singer, DE .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 2001, 285 (18) :2370-2375
[6]   Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation [J].
Hart, Robert G. ;
Pearce, Lesly A. ;
Aguilar, Maria I. .
ANNALS OF INTERNAL MEDICINE, 2007, 146 (12) :857-867
[7]   Validating the questionnaire for verifying stroke-free status (QVSFS) by neurological history and examination [J].
Jones, WJ ;
Williams, LS ;
Meschia, JF .
STROKE, 2001, 32 (10) :2232-2236
[8]   Left Atrial Appendage Closure and Systemic Homeostasis The LAA HOMEOSTASIS Study [J].
Lakkireddy, Dhanunjaya ;
Turagam, Mohit ;
Afzal, Muhammad Rizwan ;
Rajasingh, Johnson ;
Atkins, Donita ;
Dawn, Buddhadeb ;
Di Biase, Luigi ;
Bartus, Krzysztof ;
Kar, Saibal ;
Natale, Andrea ;
Holmes, David J., Jr. .
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 2018, 71 (02) :135-144
[9]   Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery [J].
Mahmood, Eitezaz ;
Matyal, Robina ;
Mahmood, Feroze ;
Xu, Xinling ;
Sharkey, Aidan ;
Chaudhary, Omar ;
Karani, Sadia ;
Khabbaz, Kamal .
CIRCULATION, 2020, 142 (01) :20-28
[10]   STROKE PREVENTION IN ATRIAL-FIBRILLATION STUDY - FINAL RESULTS [J].
MCBRIDE, R .
CIRCULATION, 1991, 84 (02) :527-539