When is atrial appendage closure during open heart surgery recommended?

Atrial Appendage Closure During Open Heart Surgery

Direct Recommendation

Surgical left atrial appendage (LAA) closure should be performed as an adjunct to oral anticoagulation in all patients with atrial fibrillation undergoing cardiac surgery, based on Class I, Level B evidence showing significant stroke reduction. 1, 2

Evidence-Based Approach

Primary Indication: Patients with Atrial Fibrillation

For patients with documented AF (paroxysmal or persistent) undergoing open heart surgery, concomitant LAA closure is strongly recommended regardless of CHA₂DS₂-VASc score. 1, 2

• The LAAOS III trial demonstrated a 33% relative risk reduction in ischemic stroke or systemic embolism (4.8% vs 7.0% in controls, HR 0.67) when LAA occlusion was added to anticoagulation during cardiac surgery 2
• This benefit was achieved when LAA closure was performed as an adjunct to anticoagulation, not as a replacement 2
• The European Society of Cardiology provides a Class I, Level B recommendation for this approach 1, 2

Emerging Evidence: Patients Without Preoperative AF

Consider LAA closure even in patients without documented AF undergoing open heart surgery, given the high incidence of postoperative AF and stroke risk. 3, 4

• Patients undergoing open heart surgery have high rates of postoperative AF with significant recurrence rates 3
• The ongoing LAACS-2 trial (1,500 patients) is investigating LAA closure in all patients undergoing open heart surgery regardless of preoperative AF status or CHA₂DS₂-VASc score 3, 4
• This represents an evolving area where future guidelines may expand indications 4

Specific Surgical Scenarios

LAA closure should also be considered during endoscopic or hybrid AF ablation procedures. 1

• The European Society of Cardiology recommends LAA closure as an adjunct to oral anticoagulation in patients undergoing endoscopic or hybrid AF ablation 1

Critical Technical Considerations

Surgical Technique Matters Significantly

The choice of surgical closure technique is critical, as incomplete occlusion paradoxically increases stroke risk. 2, 5, 6

• Excision techniques show 73% complete occlusion success rates 2
• Suture exclusion shows only 23% success rates 2
• Stapling shows 0% complete occlusion success 2
• Incomplete LAA occlusion is associated with thrombus formation in approximately 25% of cases, creating a paradoxical increase in stroke risk 2
• Epicardial closure techniques are preferred for surgical approaches 6

Anatomical Challenges

Be aware of proximity to the circumflex coronary artery and variable LAA anatomy. 2

• Damage to the circumflex coronary artery is a recognized risk due to its proximity to the LAA base 2
• Variable LAA anatomy makes consistent and complete occlusion technically challenging 2
• Major bleeding can occur during surgical manipulation 2

Post-Procedural Management

Anticoagulation Requirements

Continue oral anticoagulation after LAA closure in most patients—LAA closure does not eliminate the need for anticoagulation. 2

• The LAA is not the only left atrial region where thrombi can originate 7, 2
• The LAAOS III trial demonstrated benefit when LAA occlusion was added to anticoagulation, not as a replacement 2
• Direct oral anticoagulants (DOACs) remain first-line therapy for stroke prevention in AF patients post-operatively 1

Monitoring for Complications

Monitor for device-related thrombus formation and peri-device leaks. 2

• Device-related thrombus occurs in 1.7%-7.2% of cases and increases ischemic stroke risk 2
• Peri-device leaks (0-5 mm) are present in approximately 25% of cases 2
• Incomplete occlusion requires ongoing vigilance and may necessitate continued anticoagulation 2, 5

Common Pitfalls to Avoid

Do Not Use LAA Closure as Anticoagulation Replacement

The most critical error is discontinuing anticoagulation after LAA closure in patients who otherwise require it. 2

• LAA closure is an adjunct to, not a substitute for, oral anticoagulation in most patients 1, 2
• Only consider LAA closure as an alternative to anticoagulation in patients with absolute contraindications to long-term anticoagulation 1

Ensure Complete Occlusion

Incomplete closure is worse than no closure at all. 2, 5

• Incomplete occlusion can increase stroke risk almost 12-fold 5
• Use techniques with proven high success rates (excision preferred over stapling or suture) 2, 6
• Consider intraoperative transesophageal echocardiography to confirm complete closure 6

Avoid Inappropriate Patient Selection

Do not perform LAA closure in patients with current endocarditis or those planned for AF ablation during the same procedure. 3, 4

• Active endocarditis is a contraindication 3, 4
• Coordinate with electrophysiology if ablation is planned 3

Algorithm for Decision-Making

1. Patient has documented AF + undergoing open heart surgery → Perform LAA closure as adjunct to anticoagulation (Class I recommendation) 1, 2

2. Patient without documented AF + undergoing open heart surgery → Consider LAA closure given high postoperative AF risk (emerging evidence) 3, 4

3. Patient undergoing endoscopic/hybrid AF ablation → Consider LAA closure as adjunct to anticoagulation 1

4. Technique selection → Prioritize excision over suture or stapling methods 2, 6

5. Post-operative management → Continue oral anticoagulation in all patients unless absolute contraindication exists 1, 2