Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and strokeCentral MessagePerspective
Mariusz Kowalewski, MD, PhD,
Michał Święczkowski, MD,
Łukasz Kuźma, MD, PhD,
Bart Maesen, MD, PhD,
Emil Julian Dąbrowski, MD,
Matteo Matteucci, MD,
Jakub Batko, MD, PhD,
Radosław Litwinowicz, MD, PhD,
Adam Kowalówka, MD, PhD,
Wojciech Wańha, MD, PhD,
Federica Jiritano, MD, PhD,
Giuseppe Maria Raffa, MD, PhD,
Pietro Giorgio Malvindi, MD, PhD,
Luigi Pannone, MD,
Paolo Meani, MD, PhD,
Roberto Lorusso, MD, PhD,
Richard Whitlock, MD, PhD,
Mark La Meir, MD, PhD,
Carlo de Asmundis, MD, PhD,
James Cox, MD, PhD,
Piotr Suwalski, MD, PhD
Affiliations
Mariusz Kowalewski, MD, PhD
Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland; Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Address for reprints: Mariusz Kowalewski, MD, PhD, Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Wołoska 137 Str, 02-507 Warsaw, Poland.
Michał Święczkowski, MD
Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
Łukasz Kuźma, MD, PhD
Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
Bart Maesen, MD, PhD
Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
Emil Julian Dąbrowski, MD
Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
Matteo Matteucci, MD
Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
Jakub Batko, MD, PhD
Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
Radosław Litwinowicz, MD, PhD
Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
Adam Kowalówka, MD, PhD
Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland; Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
Wojciech Wańha, MD, PhD
Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
Federica Jiritano, MD, PhD
Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
Giuseppe Maria Raffa, MD, PhD
Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
Pietro Giorgio Malvindi, MD, PhD
Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy; Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
Luigi Pannone, MD
Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
Paolo Meani, MD, PhD
Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
Roberto Lorusso, MD, PhD
Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
Richard Whitlock, MD, PhD
McMaster University, Hamilton, Canada
Mark La Meir, MD, PhD
Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
Carlo de Asmundis, MD, PhD
Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
James Cox, MD, PhD
Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
Piotr Suwalski, MD, PhD
Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
Objective: Left atrial appendage closure (LAAC) concomitant to heart surgery in patients with underlying atrial fibrillation (AF) has gained attention because of long-term reduction of thromboembolic complications. As of mortality benefits in the setting of non-AF, data from both observational studies and randomized controlled trials are conflicting. Methods: On-line databases were screened for studies comparing LAAC versus no LAAC concomitant to other heart surgery. End points assessed were all-cause mortality and stroke at early and longest-available follow-up. Subgroup analyses stratified on preoperative AF were performed. Risk ratios (RR) with 95% CIs served as primary statistics. Results: Electronic search yielded 25 studies (N = 660 [158 patients]). There was no difference between LAAC and no LAAC in terms of early mortality. In the overall population analysis, LAAC reduced long-term mortality (RR, 0.86; 95% CI, 0.74-1.00; P = .05; I2 = 88%), reduced early stroke risk by 19% (RR, 0.81; 95% CI, 0.72-0.93; P = .002; I2 = 57%), and reduced late stroke risk by 13% (RR, 0.87; 95% CI, 0.84-0.90; P < .001; I2 = 58%). Subgroup analysis showed lower mortality (RR, 0.85; 95% CI, 0.72-1.01; P = .06; I2 = 91%), short-, and long-term stroke risk reduction only in patients with preoperative AF (RR, 0.81; 95% CI, 0.71-0.93; P = .003; I2 = 71% and RR, 0.87; 95% CI, 0.84-0.91; P < .001; I2 = 70%, respectively). No benefit of LAAC in patients without AF was found. Conclusions: Concomitant LAAC was associated with reduced stroke rates at early and long-term and possibly reduced all-cause mortality at the long-term follow-up but the benefits were limited to patients with preoperative AF. There is not enough evidence to support routine concomitant LAAC in non-AF settings.
