Is Anticoagulation Warranted after Left Atrial Appendage Ligation in Patients at Risk for Stroke after Cardiac Surgery?

Objectives: Left atrial appendage ligation (LAAL) may constitute alternative stroke prophylaxis in patients with atrial fibrillation (AF). Herein we describe the 30-day post discharge outcomes of cardiac surgery patients with elevated stroke risk with or without anticoagulation (AC) following epicardial LAAL. Methods: Data were reviewed for 479 consecutive adult patients who underwent epicardial LAAL from 2014-2019 (median CHA2DS2-VASc score = 4.0). There were 251 and 228 patients discharged with and without AC, respectively, who were followed for 30 days. Patients were matched via 1:1 Propensity Score Matching (PSM;n = 115 per group). Post-discharge outcomes included stroke, bleeding, readmission for cardiac re-intervention, mortality, and a composite endpoint comprised of the aforementioned outcomes. Results: There was no difference in post-discharge stroke incidence regardless of AC (adjusted cumulative incidence (ACI) 0.009 CI [0.001 - 0.043] with AC vs 0.009 CI [0.001 - 0.43] without AC;p = 0.826), post-discharge bleeding (ACI 0.018 CI [0.003 - 0.057] with AC vs 0.009 CI [0.001 - 0.046] without AC;p = 0.738), readmission for cardiac re-intervention (ACI 0.009 CI [0.009 - 0.009] with AC vs 0 CI [NA] without AC;p = 0.340, post-discharge mortality (ACI 0 CI NA with AC vs 0.009 CI [0.001 - 0.046] without AC;p = 0.123, or in the composite outcome (ACI 0.026 CI [0.007 - 0.069] with AC vs 0.027 CI [0.007 - 0.071] without AC;p = 0.824. Conclusion: Cessation of AC in patients with elevated stroke risk following epicardial LAAL during cardiac surgery does not affect stroke rate, mortality, or bleeding incidence up to 30 days post-discharge in this preliminary analysis.

Mitral Valve Surgery for Functional Regurgitation: Insights into Heart Failure and Readmission

Background: Functional mitral regurgitation (FMR) is an increasing burden as population ages. Mitral valve repair (MVr) is the preferred surgical treatment of FMR despite limited evidence supporting its efficacy. Mitral valve replacement (MVR) is the alternative procedure typically reserved for patients who are at higher risk or refractory to MVr. The present study aims to determine which of the two procedures is more effective in the surgical treatment of FMR. Methods: 344 charts of FMR patients who received either MVr (n = 263) or MVR (n = 81) from 2004-2016 at our institution were reviewed. Treatment efficacy was assessed based on heart failure (HF)-readmission and survival rates within 5 years from discharge. Propensity score approach with inverse probability weighting and Cox regression models were employed to evaluate procedural impact on survival and rehospitalizations, respectively. Follow-up echocardiographic data from the original cohort was assessed for differences in metrics between procedural groups at >6 months (MVr: n = 75;MVR: n = 23) and 1 year (MVr: n = 75;MVR: n = 18) post-op. Results: MVR patients had a lower risk of being readmitted for HF within 5 years compared to the MVr group (HR-adj (95% CI): 0.60 (0.41 - 0.88), p = 0.008). MVR patients also had a higher overall risk of death (HR-adj (95% CI): 1.82 (1.05 - 3.16), p = 0.034) but this was borderline significantly different at 5 years cut-off (p = 0.057). Conclusions: Higher HF readmission in MVr patients than in sicker, higher surgical-risk MVR patients reflects the inadequacy of MVr to treat FMR. Novel approaches to MVR may be necessary to adequately manage FMR.