The effectiveness of left atrial appendage occlusion during off-pump coronary artery bypass grafting in elderly patients with coronary artery disease and atrial fibrillation: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

JIANG Zhaolei ¹ ^姜 , TANG Min ¹ ^姜 ,  MEI Ju ¹ , LIU Hao ¹ , MA Nan ¹ , SHEN Saie ² , BAO Chunrong ¹ , DING Fangbao ¹

1. Department of Cardiothoracic Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao tong University, Shanghai, 200092, P.R.China;
2. Department of Anesthesiology, Xinhua Hospital, School of Medicine, Shanghai Jiao tong University, Shanghai, 200092, P.R.China;

Corresponding?author：

MEI Ju, Email: ju_mei63@126.com

Keywords：

Coronary artery disease; atrial fibrillation; left atrial appendage; stroke; minimally invasive surgery

DOI：

10.7507/1007-4848.202011036

Video：

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Objective To investigate the technique and efficacy of left atrial appendage (LAA) occlusion during off-pump coronary artery bypass grafting (OPCABG) in elderly patients with coronary artery disease (CAD) and atrial fibrillation (AF).Methods From 2013 to 2018, 84 elderly patients with CAD and AF with reduced left ventricular ejection fraction (LVEF< 50%) underwent OPCABG in our department. There were 54 males and 30 females at age of 70-82 years. They were divided into a left atrial appendage (LAA) occlusion group (n=56) and a non-LAA occlusion group (n=28). Postoperative antithrombotic therapy: the LAA occlusion group was given warfarin + aspirin + clopidogrel “triple antithrombotic therapy” for 3 months after operation, then was changed to aspirin + clopidogrel “dual antiplatelet” for long-term antithrombotic; the non-LAA occlusion group was given warfarin + aspirin + clopidogrel “triple antithrombotic” for long-term antithrombotic after operation. The clinical effectiveness of the two groups was compared.Results All patients underwent the surgery successfully. There were 56 patients in the LAA occlusion group, including 44 patients of LAA exclusion and 12 patients of LAA clip. The time of LAA occlusion was 3 to 8 minutes. There was no injury of graft vessels and anastomotic stoma. Early postoperative death occurred in 2 patients (2.4%). There was no statistical difference between the two groups in postoperative hospital stay (P=0.115). Postoperative LVEF of the two groups significantly improved compared with that before operation (P<0.05). There was no stroke or bleeding in important organs during hospitalization. During follow-up of 1 year, no cerebral infarction occurred in both groups, but the incidence of bleeding related complications in the LAA occlusion group was significantly lower than that in the non-LAA occlusion group (3.6% vs. 18.5%, P=0.036).Conclusion For elderly patients with CAD and AF with reduced LVEF, LAA occlusion during OPCABG can effectively reduce the risk of stroke and bleeding related complications, and without increasing the risk of surgery.

Citation： JIANG Zhaolei, TANG Min, MEI Ju, LIU Hao, MA Nan, SHEN Saie, BAO Chunrong, DING Fangbao. The effectiveness of left atrial appendage occlusion during off-pump coronary artery bypass grafting in elderly patients with coronary artery disease and atrial fibrillation: A retrospective cohort study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(2): 186-190. doi: 10.7507/1007-4848.202011036 Copy

1.	Jortveit J, Pripp AH, Lang?rgen J, et al. Poor adherence to guideline recommendations among patients with atrial fibrillation and acute myocardial infarction. Eur J Prev Cardiol, 2019, 26(13): 1373-1382.
2.	Feistritzer HJ, Desch S, Zeymer U, et al. Prognostic impact of atrial fibrillation in acute myocardial infarction and cardiogenic shock. Circ Cardiovasc Interv, 2019, 12(6): e007661.
3.	Romanov A, Martinek M, Pürerfellner H, et al. Incidence of atrial fibrillation detected by continuous rhythm monitoring after acute myocardial infarction in patients with preserved left ventricular ejection fraction: results of the ARREST study. Europace, 2018, 20(2): 263-270.
4.	Ruddox V, Sandven I, Munkhaugen J, et al. Atrial fibrillation and the risk for myocardial infarction, all-cause mortality and heart failure: A systematic review and meta-analysis. Eur J Prev Cardiol, 2017, 24(14): 1555-1566.
5.	Xu Y, Ouyang X, Yan L, et al. Sin1 (stress-activated protein kinase-interacting protein) regulates ischemia-induced microthrombosis through integrin αⅡbβ3-mediated outside-in signaling and hypoxia responses in platelets. Arterioscler Thromb Vasc Biol, 2018, 38(12): 2793-2805.
6.	Ezekowitz MD, Eikelboom J, Oldgren J, et al. Long-term evaluation of dabigatran 150 vs. 110 mg twice a day in patients with non-valvular atrial fibrillation. Europace, 2016, 18(7): 973-978.
7.	Hijazi Z, Hohnloser SH, Oldgren J, et al. Efficacy and safety of dabigatran compared with warfarin in patients with atrial fibrillation in relation to renal function over time-A RE-LY trial analysis. Am Heart J, 2018, 198: 169-177.
8.	van Rein N, Heide-J?rgensen U, Lijfering WM, et al. Major bleeding rates in atrial fibrillation patients on single, dual, or triple antithrombotic therapy. Circulation, 2019, 139(6): 775-786.
9.	Haller PM, Sulzgruber P, Kaufmann C, et al. Bleeding and ischaemic outcomes in patients treated with dual or triple antithrombotic therapy: systematic review and meta-analysis. Eur Heart J Cardiovasc Pharmacother, 2019, 5(4): 226-236.
10.	Lopes RD, Rao M, Simon DN, et al. Triple vs dual antithrombotic therapy in patients with atrial fibrillation and coronary artery disease. Am J Med, 2016, 129(6): 592-599.
11.	Cao Y, Tian XY, Zhang R, et al. Short- and long-term efficacy and safety of triple vs. dual antithrombotic therapy in patients with drug-eluting stent implantation and an indication for oral anticoagulation: A meta-analysis. Int J Clin Pharmacol Ther, 2016, 54(12): 950-965.
12.	Onalan O, Crystal E. Left atrial appendage exclusion for stroke prevention in patients with nonrheumatic atrial fibrillation. Stroke, 2007, 38(2 Suppl): 624-630.
13.	Bedeir K, Holmes DR, Cox JL, et al. Left atrial appendage exclusion: An alternative to anticoagulation in nonvalvular atrial fibrillation. J Thorac Cardiovasc Surg, 2017, 153(5): 1097-1105.
14.	Caliskan E, Sahin A, Yilmaz M, et al. Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery. Europace, 2018, 20(7): e105-e114.1.
15.	Emmert MY, Puippe G, Baumüller S, et al. Safe, effective and durable epicardial left atrial appendage clip occlusion in patients with atrial fibrillation undergoing cardiac surgery: first long-term results from a prospective device trial. Eur J Cardiothorac Surg, 2014, 45(1): 126-131.
16.	Goldman ME, Pearce LA, Hart RG, et al. Pathophysiologic correlates of thromboembolism in nonvalvular atrial fibrillation: Ⅰ. Reduced flow velocity in the left atrial appendage (The Stroke Prevention in Atrial Fibrillation [SPAF-Ⅲ] study). J Am Soc Echocardiogr, 1999, 12(12): 1080-1087.
17.	Ono K, Iwama M, Kawasaki M, et al. Motion of left atrial appendage as a determinant of thrombus formation in patients with a low CHADS2 score receiving warfarin for persistent nonvalvular atrial fibrillation. Cardiovasc Ultrasound, 2012, 27(10): 50.
18.	January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 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 Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration with the Society of Thoracic Surgeons. Circulation, 2019, 140(2): e125-e151.
19.	黃從新, 張澍, 黃德嘉, 等. 左心耳干預預防心房顫動患者血栓栓塞事件: 目前的認識和建議-2019. 中國心臟起搏與心電生理雜志, 2019, 33(5): 385-401.
20.	Squiers JJ, Edgerton JR. Surgical closure of the left atrial appendage: the past, the present, the future. J Atr Fibrillation, 2018, 10(5): 1642.

1. Jortveit J, Pripp AH, Lang?rgen J, et al. Poor adherence to guideline recommendations among patients with atrial fibrillation and acute myocardial infarction. Eur J Prev Cardiol, 2019, 26(13): 1373-1382.
2. Feistritzer HJ, Desch S, Zeymer U, et al. Prognostic impact of atrial fibrillation in acute myocardial infarction and cardiogenic shock. Circ Cardiovasc Interv, 2019, 12(6): e007661.
3. Romanov A, Martinek M, Pürerfellner H, et al. Incidence of atrial fibrillation detected by continuous rhythm monitoring after acute myocardial infarction in patients with preserved left ventricular ejection fraction: results of the ARREST study. Europace, 2018, 20(2): 263-270.
4. Ruddox V, Sandven I, Munkhaugen J, et al. Atrial fibrillation and the risk for myocardial infarction, all-cause mortality and heart failure: A systematic review and meta-analysis. Eur J Prev Cardiol, 2017, 24(14): 1555-1566.
5. Xu Y, Ouyang X, Yan L, et al. Sin1 (stress-activated protein kinase-interacting protein) regulates ischemia-induced microthrombosis through integrin αⅡbβ3-mediated outside-in signaling and hypoxia responses in platelets. Arterioscler Thromb Vasc Biol, 2018, 38(12): 2793-2805.
6. Ezekowitz MD, Eikelboom J, Oldgren J, et al. Long-term evaluation of dabigatran 150 vs. 110 mg twice a day in patients with non-valvular atrial fibrillation. Europace, 2016, 18(7): 973-978.
7. Hijazi Z, Hohnloser SH, Oldgren J, et al. Efficacy and safety of dabigatran compared with warfarin in patients with atrial fibrillation in relation to renal function over time-A RE-LY trial analysis. Am Heart J, 2018, 198: 169-177.
8. van Rein N, Heide-J?rgensen U, Lijfering WM, et al. Major bleeding rates in atrial fibrillation patients on single, dual, or triple antithrombotic therapy. Circulation, 2019, 139(6): 775-786.
9. Haller PM, Sulzgruber P, Kaufmann C, et al. Bleeding and ischaemic outcomes in patients treated with dual or triple antithrombotic therapy: systematic review and meta-analysis. Eur Heart J Cardiovasc Pharmacother, 2019, 5(4): 226-236.
10. Lopes RD, Rao M, Simon DN, et al. Triple vs dual antithrombotic therapy in patients with atrial fibrillation and coronary artery disease. Am J Med, 2016, 129(6): 592-599.
11. Cao Y, Tian XY, Zhang R, et al. Short- and long-term efficacy and safety of triple vs. dual antithrombotic therapy in patients with drug-eluting stent implantation and an indication for oral anticoagulation: A meta-analysis. Int J Clin Pharmacol Ther, 2016, 54(12): 950-965.
12. Onalan O, Crystal E. Left atrial appendage exclusion for stroke prevention in patients with nonrheumatic atrial fibrillation. Stroke, 2007, 38(2 Suppl): 624-630.
13. Bedeir K, Holmes DR, Cox JL, et al. Left atrial appendage exclusion: An alternative to anticoagulation in nonvalvular atrial fibrillation. J Thorac Cardiovasc Surg, 2017, 153(5): 1097-1105.
14. Caliskan E, Sahin A, Yilmaz M, et al. Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery. Europace, 2018, 20(7): e105-e114.1.
15. Emmert MY, Puippe G, Baumüller S, et al. Safe, effective and durable epicardial left atrial appendage clip occlusion in patients with atrial fibrillation undergoing cardiac surgery: first long-term results from a prospective device trial. Eur J Cardiothorac Surg, 2014, 45(1): 126-131.
16. Goldman ME, Pearce LA, Hart RG, et al. Pathophysiologic correlates of thromboembolism in nonvalvular atrial fibrillation: Ⅰ. Reduced flow velocity in the left atrial appendage (The Stroke Prevention in Atrial Fibrillation [SPAF-Ⅲ] study). J Am Soc Echocardiogr, 1999, 12(12): 1080-1087.
17. Ono K, Iwama M, Kawasaki M, et al. Motion of left atrial appendage as a determinant of thrombus formation in patients with a low CHADS2 score receiving warfarin for persistent nonvalvular atrial fibrillation. Cardiovasc Ultrasound, 2012, 27(10): 50.
18. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 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 Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration with the Society of Thoracic Surgeons. Circulation, 2019, 140(2): e125-e151.
19. 黃從新, 張澍, 黃德嘉, 等. 左心耳干預預防心房顫動患者血栓栓塞事件: 目前的認識和建議-2019. 中國心臟起搏與心電生理雜志, 2019, 33(5): 385-401.
20. Squiers JJ, Edgerton JR. Surgical closure of the left atrial appendage: the past, the present, the future. J Atr Fibrillation, 2018, 10(5): 1642.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

The effectiveness of left atrial appendage occlusion during off-pump coronary artery bypass grafting in elderly patients with coronary artery disease and atrial fibrillation: A retrospective cohort study

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