Clinical outcomes of patients referred for left atrial appendage exclusion who did and did not undergo the procedure

Trisha Gupte; Mohammed Al-Sadawi; Tiffany Luke; Eryn K Smith; Nimita Mehta; Jackson J Liang; Aman Chugh; Fred Morady; Matthew A Romano; Hakan Oral; Michael Ghannam

doi:10.1016/j.hrthm.2024.02.044

Clinical outcomes of patients referred for left atrial appendage exclusion who did and did not undergo the procedure

Heart Rhythm. 2024 Feb 23:S1547-5271(24)00216-9. doi: 10.1016/j.hrthm.2024.02.044. Online ahead of print.

Authors

Affiliations

¹ Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan.
² Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
³ Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan. Electronic address: mousajab@med.mich.edu.

PMID: 38403234
DOI: 10.1016/j.hrthm.2024.02.044

Abstract

Background: Left atrial appendage exclusion (LAAE) is an effective alternative to long-term anticoagulation in patients with atrial fibrillation. Not all patients considered for LAAE undergo the procedure because of ineligibility, anatomic or medical constraints, and preference of the patient.

Objective: The objective of this study was to report on the management strategies and long-term clinical outcomes of patients referred to a dedicated multidisciplinary LAAE clinic, including all who subsequently did and did not undergo LAAE.

Methods: This was a retrospective analysis of prospectively acquired data from all patients referred to the comprehensive multidisciplinary LAAE clinic at the University of Michigan between 2016 and 2022. A consecutive 301 patients (age, 75 ± 8 years; 106 women) with atrial fibrillation were evaluated. LAAE was performed in 168 patients (56%) with use of the Watchman device in 146 (49%) and surgically in 22 (7%). LAAE was not performed in 133 patients (44%, no-LAAE group) because of ineligibility in 62 (21%), anatomic constraints in 23 (7%), and preference of the patient in 48 (36%). The CHA₂DS₂-VASc score (4.7 ± 1.5 vs 4.1 ± 1.6; P = .002) and HAS-BLED score (3.4 ± 1.0 vs 2.8 ± 1.1; P < .001) were higher in the LAAE groups.

Results: Anticoagulant therapy was discontinued in 137 of 146 (94%) and 61 of 133 (61%) in the Watchman and no-LAAE groups, respectively (P < .001). During a median follow-up of 2.2 years (interquartile range, 1.2-4.0 years), in the LAAE (n = 168) and no-LAAE (n = 133) groups, respectively, 39 (23%) vs 29 (22%) deaths, 13 (8%) vs 5 (4%) thromboembolic events, and 24 (14%) vs 23 (17%) bleeding complications occurred. Continued long-term anticoagulation was not a predictor of clinical outcomes.

Conclusion: After a comprehensive evaluation in a multidisciplinary clinic, ∼50% of the patients referred for LAAE did not proceed with LAAE and resumed anticoagulation.

Keywords: Anticoagulation; AtriClip; Atrial fibrillation; Left atrial appendage exclusion; Watchman.