Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation: a national cohort study

  • Daniel J. Friedman
  • Jeffrey G. Gaca
  • Tongrong Wang
  • S. Chris Malaisrie
  • David R. Holmes
  • Jonathan P. Piccini
  • Rakesh M. Suri
  • Michael J. Mack
  • Vinay Badhwar
  • Jeffrey P. Jacobs
  • Eric D. Peterson
  • Shein-Chung Chow
  • J. Matthew BrennanEmail author



Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO.


In a nationally-representative, contemporary cohort (07/2011–06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models.


In this cohort (average age, 76 years; 39% female), 4177 (37%) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25% (“unprotected” patients). The overall propensity for S-LAAO decreased significantly with increasing CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (ptrend < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers.


Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA2DS2-VASc score-defined stroke risk).


Arrhythmia therapy (including ablation Surgery Drugs) Atrial fibrillation Atrial flutter 



We wish to acknowledge Felicia Graham for longitudinal project leadership, Siyi Zhang and Qingyu Li for statistical support, and Erin Campbell for editorial support.

Sources of funding

Funding for this project was made possible, in part, by the Food and Drug Administration through a grant (1U01FD004591-01), views expressed in written materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does any mention of trade names, commercial practices or organization imply endorsement by the United States Government. Dr. Friedman has been funded via the National Institutes of Health T 32 training grant HL069749.

Compliance with ethical standards

Conflict of interest disclosures

Dr. Brennan holds an Innovation in Regulatory Science Award from Burroughs Welcome Fund. Dr. Friedman has received educational grants from Boston Scientific, Abbott, and Medtronic; research grants from the National Cardiovascular Data Registry and Biosense Webster; was funded by the National Institutes of Health T 32 training grant HL069749-13; and is supported by the Joseph C. Greenfield, Jr., M.D. Scholar in Cardiology Award. Dr. Holmes and the Mayo Clinic report a financial interest in technology related to this research; that technology has been licensed to Boston Scientific. Dr. Piccini reports receiving research grant funding from Boston Scientific. The other authors report no relevant disclosures.


  1. 1.
    Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. 1998;82(8A):2N–9N.CrossRefGoogle Scholar
  2. 2.
    O’Brien SM, Shahian DM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2–isolated valve surgery. Ann Thorac Surg. 2009;88(1 Suppl):S23–42.CrossRefGoogle Scholar
  3. 3.
    Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3–valve plus coronary artery bypass grafting surgery. Ann Thorac Surg. 2009;88(1 Suppl):S43–62.CrossRefGoogle Scholar
  4. 4.
    Shahian DM, O’Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1–coronary artery bypass grafting surgery. Ann Thorac Surg. 2009;88(1 Suppl):S2–22.CrossRefGoogle Scholar
  5. 5.
    Tarakji KG, Sabik JF 3rd, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305(4):381–90.CrossRefGoogle Scholar
  6. 6.
    Whitlock R, Healey JS, Connolly SJ, Wang J, Danter MR, Tu JV, et al. Predictors of early and late stroke following cardiac surgery. CMAJ. 2014;186(12):905–11.CrossRefGoogle Scholar
  7. 7.
    Whitlock RP, Vincent J, Blackall MH, Hirsh J, Fremes S, Novick R, et al. Left atrial appendage occlusion study II (LAAOS II). Can J Cardiol. 2013;29(11):1443–7.CrossRefGoogle Scholar
  8. 8.
    Friedman DJ, Piccini JP, Wang T, Zheng J, Malaisrie SC, Holmes DR, et al. Association between left atrial appendage occlusion and readmission for thromboembolism among patients with atrial fibrillation undergoing concomitant cardiac surgery. JAMA. 2018;319(4):365–74.CrossRefGoogle Scholar
  9. 9.
    Yao X, Gersh BJ, Holmes DR Jr, Melduni RM, Johnsrud DO, Sangaralingham LR, et al. Association of surgical left atrial appendage occlusion with subsequent stroke and mortality among patients undergoing cardiac surgery. JAMA. 2018;319:2116–26.CrossRefGoogle Scholar
  10. 10.
    January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014. 2014;64(21):e1–76.CrossRefGoogle Scholar
  11. 11.
    Bennett-Guerrero E, Zhao Y, O'Brien SM, Ferguson TB Jr, Peterson ED, Gammie JS, et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA. 2010;304(14):1568–75.CrossRefGoogle Scholar
  12. 12.
    Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of diet in renal disease study group. Ann Intern Med. 1999;130(6):461–70.CrossRefGoogle Scholar
  13. 13.
    The Society of Thoracic Surgeons (STS). Adult cardiac surgery database data. STS web site. Accessed August 14, 2018.
  14. 14.
    Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137(2):263–72.CrossRefGoogle Scholar
  15. 15.
    Holmes DR Jr, Doshi SK, Kar S, Price MJ, Sanchez JM, Sievert H, et al. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis. J Am Coll Cardiol. 2015;65(24):2614–23.CrossRefGoogle Scholar
  16. 16.
    Holmes DR Jr, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, et al. Prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64(1):1–12.CrossRefGoogle Scholar
  17. 17.
    Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009;374(9689):534–42.CrossRefGoogle Scholar
  18. 18.
    Tsai YC, Phan K, Munkholm-Larsen S, Tian DH, La Meir M, Yan TD. Surgical left atrial appendage occlusion during cardiac surgery for patients with atrial fibrillation: a meta-analysis. Eur J Cardiothorac Surg. 2015;47(5):847–54.CrossRefGoogle Scholar
  19. 19.
    Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm. 2012. 2012;9(4):632–96.e21.CrossRefGoogle Scholar
  20. 20.
    Whitlock R, Healey J, Vincent J, Brady K, Teoh K, Royse A, et al. Rationale and design of the left atrial appendage occlusion study (LAAOS) III. Ann Cardiothorac Surg. 2014;3(1):45–54.Google Scholar
  21. 21.
    Piccini JP, Hernandez AF, Zhao X, Patel MR, Lewis WR, Peterson ED, et al. Quality of care for atrial fibrillation among patients hospitalized for heart failure. J Am Coll Cardiol. 2009;54(14):1280–9.CrossRefGoogle Scholar
  22. 22.
    García-Fernández MA, Pérez-David E, Quiles J, Peralta J, García-Rojas I, Bermejo J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol. 2003;42(7):1253–8.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Daniel J. Friedman
    • 1
  • Jeffrey G. Gaca
    • 2
  • Tongrong Wang
    • 3
  • S. Chris Malaisrie
    • 4
  • David R. Holmes
    • 5
  • Jonathan P. Piccini
    • 1
  • Rakesh M. Suri
    • 6
  • Michael J. Mack
    • 7
  • Vinay Badhwar
    • 8
  • Jeffrey P. Jacobs
    • 9
  • Eric D. Peterson
    • 1
  • Shein-Chung Chow
    • 3
  • J. Matthew Brennan
    • 1
    Email author
  1. 1.Duke Clinical Research InstituteDurhamUSA
  2. 2.Division of Cardiovascular and Thoracic SurgeryDuke UniversityDurhamUSA
  3. 3.Department of Biostatistics and BioinformaticsDuke UniversityDurhamUSA
  4. 4.Division of Cardiac SurgeryNorthwestern UniversityChicagoUSA
  5. 5.Division of Cardiovascular DiseasesMayo ClinicRochesterUSA
  6. 6.Division of Cardiovascular SurgeryMayo ClinicRochesterUSA
  7. 7.Division of Cardiovascular SurgeryBaylor UniversityDallasUSA
  8. 8.Department of Cardiovascular and Thoracic SurgeryWest Virginia UniversityMorgantownUSA
  9. 9.Hopkins All Children’s Heart InstituteSaint PetersburgUSA

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