Long-term outcomes of preventive left atrial appendage ligation during off-pump coronary artery bypass.

Abstract

Objective: The purpose of this study was to evaluate the impact of left atrial appendage closure in patients with coronary artery disease and without atrial fibrillation undergoing off-pump coronary artery bypass on the development of ischemic stroke and mortality in long-term follow-up.

Patients and methods: We performed a retrospective review of 316 patients who underwent off-pump coronary artery bypass from January 2011 to December 2011 at our institution.

Exclusion criteria: acute coronary syndrome, conversion to on-pump coronary artery bypass grafting, redo procedure, left-sided intracardiac thrombus, atrial fibrillation in history, hemodynamically significant lesions of the brachiocephalic vessels, concomitant cardiac surgery, secondary to off pump coronary artery bypass and left atrial appendage closure, and minimally invasive access. After propensity score matching, 250 patients were recruited (mean age 58.0±7.5 years). Depending on the intervention on the left atrial appendage, two groups were formed: 170 patients with left atrial appendage ligation (mean age 57.8±7.7 years) and 80 patients without left atrial appendage ligation (mean age 58.3±7.5 years). The primary endpoints were stroke, all-cause death, and a composite endpoint (ischemic stroke + all-cause death in hospital and during long-term follow-up). Secondary endpoints: resternotomy for bleeding, perioperative myocardial infarction, postoperative atrial fibrillation, length of stay in intensive care and clinic. The median follow-up period was 100 (72-105) months.

Results: Both groups were comparable in terms of baseline demographic and operational characteristics. After propensity score matching, there were no statistically significant differences between the groups in the incidence of stroke (0.6% versus 1.3%, p=0.538), all-cause mortality (0% versus 1.3%, 0.320), or composite endpoint (stroke + mortality from all causes) (0.6% versus 2.5%, p=0.241). Similarly, other results remained similar (p>0.05). During follow-up, 27 patients developed stroke (n=12 in the ligation of left atrial appendage group and n=15 in the non-left atrial appendage ligation group), while 38 patients died [n=17 (10%) and n=21 (26%), respectively]. Kaplan-Meier curves showed that there were no significant differences for the primary endpoints during long-term follow-up in the incidence of stroke (p=0.250), mortality (p=0.560), and composite endpoint (stroke + all-cause mortality) (p=0.320).

Conclusion: Routine epicardial ligation of the left atrial appendage during off-pump coronary artery bypass in patients without atrial fibrillation was not associated with reduction of risk for stroke, all-cause death, and a composite of stroke and all-cause death in hospital and during long-term follow-up.