Abstract
Post-operative atrial fibrillation (POAF) occurs in 30-40% of cardiac surgery (CS) patients (pts). Routine care for managing POAF is variable. Oral anticoagulation (OAC) may be prescribed to prevent thromboembolic events (TEs) but has a bleeding risk. Since the left atrial appendage (LAA) is the primary site of thrombus formation with AF, prophylactic LAA exclusion (LAAE) during CS may mitigate TE risk. The ATLAS prospective, randomized, multi-center, feasibility trial evaluated TE and major bleeding rates with and without LAAE in CS pts who developed POAF. Pts without pre-existing AF, HAS-BLED≥2, CHA2DS2-VASc≥2, undergoing valvular or CABG surgery were randomized 2:1 to concomitant LAAE (epicardial clip) or No LAAE. OAC was per centers’ routine care. POAF pts were followed for 1 yr. 23 sites enrolled 562 pts (376 LAAE, 186 No LAAE). Baseline parameters were similar in LAAE Vs No LAAE arms: age 69.2 Vs 68.9 yrs, HAS-BLED: 2.8 Vs. 2.9, CHA2DS2-VASc: 3.4 Vs 3.4. LAAE was successful in 99%, procedural SAE rate was 0.3%. No LAAE-related renal failures were reported. Mortality was similar between arms at 30 days and 1 yr (p=0.35, p=0.36). POAF developed in 47.3% (178) of LAAE and 38.2% (71) of No LAAE pts (p=0.047). OAC was used in 31% of LAAE Vs. 35% of No LAAE. Through 1 yr, LAAE resulted in 51% reduction in TEs Vs. No LAAE (p=0.40). Bleeding rate on OACs was 23% Vs. 5.4% without OACs (p=0.005) and was similar for both in LAAE and No LAAE groups. Prophylactic LAAE in high-risk CS pts trended towards reduced TE Vs. No LAAE. OAC use increased bleeding risk. Adequately powered RCTs of prophylactic LAAE during CS should be planned.
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