Follow-up imaging after surgical LAA occlusion uncommon
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Fewer than half of patients who underwent left atrial appendage occlusion during open-heart surgery had follow-up imaging to determine whether anticoagulation was still needed, researchers reported.
At the American College of Cardiology Scientific Session, Karuppiah Arunachalam, MD, cardiologist at Aultman Hospital in Canton, Ohio, and assistant professor of medicine at Northeast Ohio University, presented results of a retrospective chart review of 87 patients who underwent surgical left atrial appendage (LAA) occlusion with the AtriClip LAA Exclusion System (Atricure).
“Known and new-onset atrial fibrillation management after open-heart surgeries falls into the gray area due to the fact that patients are not followed up adequately from atrial fibrillation perspective and guidelines are not extensive enough to provide a clear vision regarding anticoagulation strategy after left atrial appendage occlusion or excision,” Arunachalam told Healio.
Among the cohort, one patient died postoperatively and the rest were followed for a mean of 81 months.
According to the researchers, 76 patients had baseline or postoperative atrial arrhythmias requiring stroke prophylaxis, but only 43% of those had an imaging assessment of the LAA occlusion (transesophageal echocardiography in 30 patients, intracardiac echocardiogram in three patients).
“Follow-up imaging after AtriClip placement is not performed adequately both due to patient- and clinician-related factors,” Arunachalam told Healio. “Inadequate occlusion of the left atrial appendage is common and can potentially lead to ischemic stroke due to thrombus formation.”
Among patients who had an imaging assessment, 21% had an indication for long-term anticoagulation. In six patients, it was due to device failure or a residual pouch of 10 mm or more, and in one patient it was due to LA thrombus, according to the researchers.
“Ischemic stroke can be prevented by prompt imaging follow-up using [transesophageal echocardiogram] or intracardiac echo on patients with inadequate closure of the left atrial appendage by AtriClip,” Arunachalam told Healio. “Unnecessary continuation of anticoagulation due to lack of follow-up can be avoided if the left atrial appendage is occluded appropriately and adequately on an imaging study. Discontinuation of anticoagulants are huge psychological relief for patients and benefits them economically as well. AtriClip placement follow-up should be part of guidelines, similar to post-Watchman (Boston Scientific) surveillance in various society guidelines.”
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Arunachalam K, et al. Stroke Risk Reduction in Atrial Fibrillation. Presented at: American College of Cardiology Scientific Session; May 15-17, 2021 (virtual meeting).
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