Prophylactic left atrial appendage ligation during coronary artery bypass grafting: A propensity score-matched analysis

Sean W W Noona; Steven D Young; Matthew P Weber; Mohamad El Moheb; Anthony V Norman; Alex M Wisniewski; Raymond J Strobel; Mohammed Quader; Michael A Mazzeffi; Leora T Yarboro; Jared P Beller; Nicholas R Teman

doi:10.1016/j.jtcvs.2024.08.004

Prophylactic left atrial appendage ligation during coronary artery bypass grafting: A propensity score-matched analysis

J Thorac Cardiovasc Surg. 2024 Aug 15:S0022-5223(24)00688-3. doi: 10.1016/j.jtcvs.2024.08.004. Online ahead of print.

Affiliations

¹ Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va. Electronic address: swn5dv@uvahealth.org.
² Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
³ Department of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Va.
⁴ Department of Anesthesiology, University of Virginia, Charlottesville, Va.

PMID: 39153715
DOI: 10.1016/j.jtcvs.2024.08.004

Abstract

Objective: The study objective was to evaluate short-term outcomes and statewide practice patterns of prophylactic left atrial appendage ligation in patients undergoing coronary artery bypass grafting without preoperative atrial fibrillation.

Methods: Adult patients who underwent on-pump coronary artery bypass grafting (2017-2023) within a regional collaborative were identified. Patients with a history of atrial fibrillation, previous cardiac surgery, or nondevice-based left atrial appendage ligation were excluded. Patients were stratified by left atrial appendage ligation status and were propensity score matched. Univariable analysis was used to compare short-term clinical outcomes.

Results: Of 16,547 patients examined, 442 underwent prophylactic left atrial appendage ligation. The propensity score-matched cohort (439 in the prophylactic left atrial appendage ligation group, 439 in the no prophylactic left atrial appendage ligation group) was compared and had no significant differences in preoperative Congestive heart failure, Hypertension, Age ≥ 75 (doubled), Diabetes mellitus, prior Stroke, Transient ischemic attack or Thromboembolism (doubled), Vascular disease, Age 65 to 74, Sex category (female)(CHA₂DS₂-VASc) scores or operative variables. The prophylactic left atrial appendage ligation group had longer crossclamp time (82 vs 76 minutes, P = .001), intensive care unit hours (72 vs 66, P = .001), and length of stay (6.0 vs 6.0 days, P = .010); increased postoperative atrial fibrillation (35% vs 24%, P < .001); and more discharges on anticoagulation (17% vs 8.2%, P < .001). There were no significant differences in postoperative stroke (1.1% vs 2.1%, P = .423), readmission (13% vs 9.6%, P = .118), operative mortality (2.5% vs 1.6%, P = .480), or readmission for thrombotic or bleeding complications (0.7% vs 1.1%, P = .724). Hospitalization costs were significantly higher for the prophylactic left atrial appendage ligation group ($43,478 vs $40,645, P < .001). The rate of prophylactic left atrial appendage ligation during coronary artery bypass grafting increased from 1.61% (2017) to 5.65% (2023) (P < .001).

Conclusions: Despite higher rates of postoperative atrial fibrillation, discharge on anticoagulation, and hospitalization costs in patients undergoing prophylactic left atrial appendage ligation during coronary artery bypass grafting, there was no difference in short-term clinical end points including stroke and operative mortality.

Keywords: CABG; cost; left atrial appendage ligation; prophylactic.