Long-Term Efficacy and Anticoagulation Strategy of Left Atrial Appendage Occlusion During Total Thoracoscopic Ablation of Atrial Fibrillation to Prevent Ischemic Stroke

Ju Youn Kim; Dong Seop Jeong; Seung-Jung Park; Kyoung-Min Park; June Soo Kim; Young Keun On

doi:10.3389/fcvm.2022.853299

Long-Term Efficacy and Anticoagulation Strategy of Left Atrial Appendage Occlusion During Total Thoracoscopic Ablation of Atrial Fibrillation to Prevent Ischemic Stroke

Front Cardiovasc Med. 2022 Mar 31:9:853299. doi: 10.3389/fcvm.2022.853299. eCollection 2022.

Authors

Ju Youn Kim¹, Dong Seop Jeong², Seung-Jung Park¹, Kyoung-Min Park¹, June Soo Kim¹, Young Keun On¹

Affiliations

¹ Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Heart Vascular and Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea.
² Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.

Abstract

Objectives: Atrial fibrillation (AF) is associated with an increased ischemic stroke, and the left atrial appendage (LAA) represents the main source of thrombus formation. We evaluated the long-term efficacy of surgical thoracoscopic LAA occlusion during total thoracoscopic ablation of AF to prevent the stroke and anticoagulation strategy after surgery.

Methods: Patients who underwent total thoracoscopic ablation for AF, from February 2012 to May 2020, were included; Patients who did not receive LAA occlusion were excluded. We evaluated the development of thromboembolism in these patients.

Results: The total number of 460 patients [mean age, 57.1 ± 9.2 years; 400 (87.0%) males] were included in the study. The mean follow-up duration was 44.8 months. The mean CHA₂DS₂-VASc score was 1.9 ± 1.6. Median OAC duration was 109.5 days after the surgery, and the final number of patients who discontinued OAC were 411 (89.3%) in total. Anticoagulation discontinuation rate according to CHA₂DS₂-VASc score are as follows; (i) 0 = 99.0%; (ii) 1 = 98.2%; and (iii) ≥2 = 81.3%. The annualized incidence rate of ischemic stroke was 0.78%/year, showing a 73% risk reduction compared with the CHA₂DS₂-VASc predicted rate without anticoagulation. The hazard ratio for ischemic stroke according to previous stroke history was 1.5 [95% confidential interval (CI) 0.3-7.3, p = 0.62], and that of remnant LAA was 5.1 (1.2-20.9, p = 0.02).

Conclusions: Thoracoscopic LAA occlusion during total thoracoscopic ablation of AF was effective to prevent ischemic stroke. Most patients could discontinue OAC therapy after the procedure. Patients who had a residual trabeculated LAA, or peri-occluder pouch in follow-up CT need to maintain OAC therapy even after LAA occlusion.

Keywords: anticoagulation; appendage; atrial fibrillation; ischemic stroke; thoracoscope surgery.