Association of Physician Certification and Outcomes Among Patients Undergoing Left Atrial Appendage Occlusion

Amit N Vora; Lucy A Pereira; Chengan Du; Zhen Tan; Chien Yu Huang; Daniel J Friedman; Yongfei Wang; Kamil F Faridi; Dhanunjaya R Lakkireddy; Sarah Zimmerman; Angela Y Higgins; Samir R Kapadia; Jeptha P Curtis; James V Freeman

doi:10.1016/j.jcin.2024.10.020

Association of Physician Certification and Outcomes Among Patients Undergoing Left Atrial Appendage Occlusion

JACC Cardiovasc Interv. 2024 Oct 16:S1936-8798(24)01406-7. doi: 10.1016/j.jcin.2024.10.020. Online ahead of print.

Authors

Affiliations

¹ Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA. Electronic address: amit.vora@yale.edu.
² Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, CT, USA.
³ Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
⁴ Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, CT, USA.
⁵ Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS, USA.
⁶ Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
⁷ Division of Cardiology, Maine Health, Scarborough, ME, USA.
⁸ Cleveland Clinic Foundation, Cleveland, OH USA.

PMID: 39474982
DOI: 10.1016/j.jcin.2024.10.020

Abstract

Background: Percutaneous left atrial appendage occlusion (LAAO) is indicated in patients with atrial fibrillation for whom long-term oral anticoagulation is contraindicated. Whether outcomes are different based on operator certification [interventional cardiology (IC) versus electrophysiology (EP)] is unclear.

Objectives: To compare LAAO outcomes by physician certification (EP versus IC) in the NCDR LAAO Registry.

Methods: We identified patients from 2020-2022 undergoing implantation of a Watchman FLX or Amulet LAAO device and stratified patients by primary operator certification. Outcomes of interest included: (1) any major adverse event (MAE), 2) mortality, 3) ischemic stroke, and 4) major bleeding during the initial hospitalization and at 45 days. We performed multivariable Cox proportional hazards regression analysis to determine the risk of adverse events by physician certification.

Results: A total of 1,638 physicians (57% electrophysiologists) performing 91,711 procedures during the study period were included. EPs were more likely to use intracardiac echocardiography (25.2% vs 9.7%, p<0.001) and had lower radiation total (235 mGy vs 305 mGy, p<0.001). EPs were more likely than ICs to discharge patients on DOAC+aspirin, whereas ICs were more likely to discharge patients on single or dual antiplatelet therapy (all p<0.001). In-hospital death (0.1% vs. 0.1%, p=0.46) and MAE (1.5% vs 1.6%, p=0.42) were similar by physician certification. At 45 days, there was no difference in death [HR_death 1.03, 95% CI (0.89-1.2)] or MAE [HR_MAE 0.97, 95% CI (0.91-1.03)] after multivariable regression.

Conclusions: Contemporary LAAO is safe with low rates of procedural complications and no significant differences in procedural outcomes by operator subspecialty after multivariable adjustment. Continued utilization of technology by EPs and ICs is necessary to allow for broad access to this treatment for eligible patients.

Keywords: left atrial appendage occlusion; operator certification; outcomes.