Left atrial appendage closure during cardiac surgery: Safe but underutilized in California

Abstract

ObjectiveLeft atrial appendage (LAA) closure is associated with reduced rates of stroke in patients with atrial fibrillation (AF). We evaluated trends in LAA closure, the association of LAA closure with stroke/systemic embolism, and its safety profile in patients with AF who underwent cardiac surgery in California. We further tested for hospital-level variation in concomitant LAA closure. MethodsAdults who underwent coronary artery bypass grafting and/or valve surgery with preoperative AF were identified in the 2016 to 2019 Office of Statewide Health Planning and Development databases. Propensity score matching was performed to study risk-adjusted associations of LAA closure with ischemic stroke/systemic embolism. Hospital-level variation was studied using intraclass correlation coefficients. ResultsAmong 18,434 patients with AF who underwent coronary artery bypass grafting/valve surgery, 47.7% received LAA closure. Rates of LAA closure increased from 44.4% to 51.4% from 2016 to 2019 (P < .001). In 4652 propensity score-matched patients, LAA closure was associated with reduced incidence of stroke/systemic embolism at discharge (1.6% vs 3.1%; P < .001) and readmission with stroke/systemic embolism at 1 year (2.9% vs 4.5%; P = .004). LAA closure was not associated with acute kidney injury, pulmonary complications, blood transfusion, reoperation, or in-hospital mortality. Approximately 18% of the risk-adjusted variation in LAA use was attributed to the hospital, with median center-level rate of 44.9% (interquartile range, 29.6%-57.4%). ConclusionsLAA closure was associated with minimal surgical morbidity, and reduced short- and midterm incidence of stroke/systemic embolism. Although the use of LAA closure has increased, substantial variation exists among programs in California, suggesting the need for further standardization of care.