Surgically occluded left atrial appendages (LAAs) were identified in 14% of patients with a history of atrial fibrillation and open-heart surgery, with incomplete LAA closure in 1 of 5 patients, new patient data report. The findings come from a research letter published in online Monday and in the May 14 issue of the Journal of the American College of Cardiology, which noted that surgical left atrial appendage occlusion (LAAO) is performed in up to 50% of patients with atrial fibrillation undergoing open-heart surgery, and that despite a similar biological mechanism of stroke reduction with percutaneous or surgical LAAO, there is a disconnect in the recommendation for anticoagulation following the LAAO modalities. “It is routine practice to discontinue anticoagulation following percutaneous LAAO; however, there are no clear recommendations for anticoagulation following surgical LAAO,” said the authors, led by Tarun Chakravarty, MD, and colleagues from the from Cedars-Sinai Medical Center, Los Angeles, adding that the study reported in the research letter evaluated trends in the use and safety of long-term anticoagulation for atrial fibrillation in patients with surgically occluded LAAs. Study details Chakravarty and colleagues analyzed data from 721 patients with a history of atrial fibrillation and open-heart surgery who underwent transcatheter valve interventions (transcatheter heart valve replacement or transcatheter mitral valve repair) from October 2014 through July 2023 at Cedars-Sinai for whom computed tomography (CT) scans or transesophageal echocardiography (TEE) data were present. Patients who did not have evaluable CT or TEE images for LAA were presumed to have patent LAAs, unless surgical LAAO was documented in the clinical notes, they said, adding that patients had a mean age of 76 years and 43% were women. They reported that surgically occluded LAAs were noted in 98 of 721 (14%) patients and confirmed with CT in 84 of 98 (86%) and TEE in 14 of 98 (14%) patients, while incompletely occluded LAAs, with residual flow into the appendage, were noted in 19 of 98 (19%) patients. “Surgery was performed at our hospital in 36 of 98 (37%) patients and at another hospital in 62 of 98 (63%) patients," said the authors, noting that outside hospital details were not available for 31 patients at 22 hospitals. Furthermore, they noted that details of the surgical technique of LAAO were not available. A total of 70 of the 98 patients (71%) with surgically occluded LAAs were on anticoagulation, they noted, adding that the primary indication for anticoagulation was atrial fibrillation in 61 of 70 (87%) patients, while nine of those 61 patients had a second reason for anticoagulation – including mechanical heart valves (n = 9) and deep vein thrombosis/pulmonary embolism (n = 1). Chakravarty and colleagues reported that 16 of 70 patients were on anticoagulation despite a history of anticoagulation-related bleeding complications, five of 70 patients were on anticoagulation despite having previously required a major surgery for anticoagulation-related, and one patient was referred for a percutaneous LAAO procedure due to anticoagulation-related recurrent bleeding. “Of the 28 patients who were not on anticoagulation, 8 patients had previously been on anticoagulation that was subsequently discontinued due to bleeding complications,” they said, noting that the use of anticoagulation was similar in patients with complete or incomplete LAAO (56 of 79 [71%] patients vs 14 of 19 [74%] patients; P = 0.81). Furthermore, surgically occluded LAAs were not documented in 64 of 98 (65%) interventional cardiology notes, 78 of 98 (80%) cardiothoracic surgery notes, 66 of 84 (79%) CT reports, and 84 of 98 (86%) TEE reports, they added. Clinical implications The authors warned that it is important to perform follow-up imaging with TEE or CT (as percutaneous LAAO practices) to assess the completeness of LAA closure and effectiveness of the different surgical techniques of LAAO. “Despite the advanced age, high bleeding risk and multiple bleeding complications (occasionally even requiring surgical management), most patients with surgically occluded LAA were on long-term anticoagulation for atrial fibrillation,” they said, noting that although the safety profile of anticoagulation may be acceptable early after surgery, the bleeding risk increases with age and development of comorbidities. “It may be reasonable to extrapolate the data from the percutaneous LAAO trials and consider discontinuing anticoagulation in high bleeding–risk patients with surgically occluded LAA.” The team also noted that while the history of open-heart surgery and the type of surgery were routinely documented in the physician notes, documentation of a surgically occluded LAA was frequently missing in physician notes and imaging reports – “suggesting that most physicians did not consider or were even aware, of the history of surgical LAAO when evaluating patients with atrial fibrillation.” “It is imperative for all treating physicians to rule out surgically occluded LAA before prescribing anticoagulation for atrial fibrillation to patients with prior open-heart surgery,” the team warned, adding that when a surgical operative report is not available or if there is concern for incompletely occluded LAA, CT or TEE imaging should be considered to evaluate the LAA. Source: Chakravarty T, Solanki A, Bhardwaj N, et al Anticoagulation for Atrial Fibrillation in Patients With Surgically Occluded Left Atrial Appendage. J Am Coll Cardiol 2024;83:1936-1938. Image Credit: Robert – stock.adobe.com