Elbadawi Ayman, Ogunbayo Gbolahan O, Elgendy Islam Y, Olorunfemi Odunayo, Saad Marwan, Ha Le Dung, Alotaki Erfan, Baig Basarat, Abuzaid A S, Shahin Hend I, Shah Abrar, Rao Mohan
Department of Internal Medicine, Rochester General Hospital, Rochester, New York.
Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
Am J Cardiol. 2017 Sep 15;120(6):953-958. doi: 10.1016/j.amjcard.2017.06.025. Epub 2017 Jun 28.
Left atrial appendage (LAA) exclusion is performed by some surgeons in patients with atrial fibrillation (AF) who undergo coronary artery bypass grafting (CABG). However, the available evidence regarding the efficacy and safety of this procedure remains mixed. We queried the Nationwide Inpatient Survey Database for the 10-year period from 2004 to 2013. Using International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis codes, we identified patients who had a diagnosis of AF and underwent a primary procedure of CABG with or without LAA exclusion. We then performed a 1:5 matching based on the CHADSVASc score between patients who got LAA exclusion and those who did not (control group). The primary outcome was the incidence of in-hospital cerebrovascular events, whereas the secondary outcomes included in-hospital bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and mortality. Our analysis included a total of 15,114 patients. Patients who underwent LAA exclusion had significantly less incidence of cerebrovascular events (2.0% vs 3.1%, p = 0.002). However, LAA exclusion group had higher incidences of bleeding events (36.4% vs 21.3%, p <0.001), pericardial effusion (2.7% vs 1.2%, p <0.001), cardiac tamponade (0.6% vs 0.2%, p <0.001), and postoperative shock (1.2% vs 0.4%, p <0.001). LAA exclusion was associated with higher in-hospital mortality (1.6% vs 0.3%, p <0.001). Multivariate regression analysis showed that LAA exclusion was significantly associated with lower cerebrovascular accident events and higher in-hospital mortality. In conclusion, LAA exclusion in patients with AF undergoing CABG might be associated with a lower incidence of in-hospital cerebrovascular events. This benefit is offset by a higher incidence of higher bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and in-hospital mortality.
对于接受冠状动脉旁路移植术（CABG）的心房颤动（AF）患者，一些外科医生会进行左心耳（LAA）封堵术。然而，关于该手术有效性和安全性的现有证据仍存在分歧。我们查询了2004年至2013年这10年间的全国住院患者调查数据库。使用国际疾病分类第九版临床修订本诊断代码，我们确定了诊断为AF且接受了有或无LAA封堵术的CABG主要手术的患者。然后，我们根据CHADSVASc评分对接受LAA封堵术的患者和未接受LAA封堵术的患者（对照组）进行了1:5匹配。主要结局是院内脑血管事件的发生率，次要结局包括院内出血事件、心包积液、心脏压塞、术后休克和死亡率。我们的分析共纳入了15114例患者。接受LAA封堵术的患者脑血管事件发生率显著较低（2.0%对3.1%，p = 0.002）。然而，LAA封堵术组的出血事件发生率更高（36.4%对21.3%，p <0.001）、心包积液发生率更高（2.7%对1.2%，p <0.001）、心脏压塞发生率更高（0.6%对0.2%，p <0.001）以及术后休克发生率更高（1.2%对0.4%，p <0.001）。LAA封堵术与更高的院内死亡率相关（1.6%对0.3%，p <0.001）。多变量回归分析表明，LAA封堵术与较低的脑血管意外事件和较高的院内死亡率显著相关。总之，在接受CABG的AF患者中进行LAA封堵术可能与较低的院内脑血管事件发生率相关。但这种益处被更高的出血事件、心包积液、心脏压塞、术后休克和院内死亡率所抵消。
