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Left atrial appendage obliteration in atrial fibrillation patients undergoing bioprosthetic mitral valve replacement

Obliteration des linken Herzohrs bei Patienten mit Vorhofflimmern und bioprothetischem Mitralklappenersatz

Abstract

Background

Left atrial appendage (LAA) obliteration is a proven stroke-preventive measure for patients with nonvalvular atrial fibrillation (AF). However, the efficacy of LAA obliteration for patients with AF after bioprosthetic mitral valve replacement (MVR) remains unclear.

Aim

This study aimed to estimate the efficacy of LAA obliteration in preventing embolism and to investigate the predictors of thromboembolism after bioprosthetic MVR.

Methods

We retrospectively studied 173 AF subjects with bioprosthetic MVR; among them, 81 subjects underwent LAA obliteration using an endocardial running suture method. The main outcome measure was the occurrence of thrombosis events (TEs). The mean follow-up time was 40 ± 17 months.

Results

AF rhythm was observed in 136 patients postoperatively. The incidence rate of TEs was 13.97 % for postoperative AF subjects; a dilated left atrium (LA; > 49.5 mm) was identified as an independent risk factor of TEs (OR = 10.619, 95 % CI = 2.754–40.94, p = 0.001). For postoperative AF patients with or without LAA, the incidence rate of TEs was 15.8 % (9/57) and 12.7 % (10/79; p = 0.603), respectively. The incidence rate of TEs was 2.7 % (1/36) and 4.2 % (2/48) for the subgroup patients with a left atrial diameter of < 49.5 mm, and 38.1 % (8/21) and 25.8 % (8/31) for those with a left atrial diameter of > 49.5 mm (p = 0.346).

Conclusion

Surgical LAA obliteration in patients with valvular AF undergoing bioprosthetic MVR did not reduce TEs, even when the CHA2DS2-VASc score (a score for estimating the risk of stroke in AF) was ≥ 2 points.

Zusammenfassung

Hintergrund

Die Obliteration des linken Herzohrs („left atrial appendage“, LAA) ist nachgewiesenermaßen ein Verfahren zur Prävention des Schlaganfalls bei Patienten mit nichtvalvulärem Vorhofflimmern (VF). Die Wirksamkeit der LAA-Obliteration bei Patienten mit VF nach Mitralklappenersatz („mitral valve replacement“, MVR) mit einer Bioprothese bleibt jedoch unklar.

Ziel

Die vorliegende Studie zielt darauf ab, die Wirksamkeit der LAA-Obliteration bei der Verhütung von Embolien abzuschätzen und Prädiktoren der Thromboembolie nach bioprothetischem MVR zu untersuchen.

Methoden

Retrospektiv wurden 173 Patienten mit VF und bioprothetischem MVR untersucht, in 81 Fällen davon war eine LAA-Obliteration mit fortlaufender Endokardnaht erfolgt. Hauptendpunktparameter war das Auftreten thrombotischer Ereignisse (TE). Die Nachbeobachtungsdauer lag im Durchschnitt bei 40 ± 17 Monaten.

Ergebnisse

Postoperativ bestand bei 136 Patienten ein VF. Die TE-Inzidenzrate betrug 13,97 % bei den Teilnehmern mit postoperativem VF; ein dilatierter linken Vorhof (> 49,5 mm) wurde als unabhängiger Risikofaktor für TE ermittelt (Odds Ratio, OR: 10,619; 95 %-Konfidenzintervall: 2,754–40,94; p = 0,001). Für Patienten mit postoperativem VF mit bzw. ohne LAA lag die Inzidenzrate für TE bei 15,8 % (9/57) bzw. 12,7 % (10/79; p = 0,603), und bei 2,7 % (1/36) bzw. 4,2 % (2/48) für die Untergruppe mit einem linken Vorhof < 49,5 mm; dagegen bei 38,1 % (8/21) bzw. 25,8 % (8/31) für Patienten mit einem linken Vorhof > 49,5 mm (p = 0,346).

Schlussfolgerung

Durch eine chirurgische LAA-Obliteration bei Patienten mit valvulärem VF und bioprothetischem MVR wurden TE nicht vermindert, selbst wenn der CHA2DS2-VASc-Score (Score zur Abschätzung des Schlaganfallrisikos bei VF) bei ≥ 2 Punkten lag.

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Correspondence to X. Meng.

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Conflict of interest

X-P. Min, T-Y. Zhu, J. Han, Y. Li, and X. Meng state that there are no conflicts of interest. All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.

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Min, X., Zhu, T., Han, J. et al. Left atrial appendage obliteration in atrial fibrillation patients undergoing bioprosthetic mitral valve replacement. Herz 41, 87–94 (2016). https://doi.org/10.1007/s00059-015-4350-z

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Keywords

  • Left atrial appendage
  • Left atrial dimension
  • Thrombosis events
  • Atrial fibrillation
  • Bioprosthetic mitral valve replacement

Schlüsselwörter

  • Linkes Herzohr
  • Ausmaß des linken Vorhofs
  • Thrombotische Ereignisse
  • Vorhofflimmern
  • Bioprothetischer Mitralklappenersatz