Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine.
Department of Cardiovascular Surgery, Toda Chuo General Hospital.
Circ J. 2023 Jun 23;87(7):982-989. doi: 10.1253/circj.CJ-22-0573. Epub 2023 Mar 17.
Patients with end-stage renal disease on hemodialysis (ESRD-HD) have a lifelong risk of atrial fibrillation-related stroke. We compared clinical outcomes in ESRD-HD patients undergoing coronary artery bypass grafting (CABG) with and without concomitant left atrial appendage (LAA) closure.
Of 2,783 consecutive patients undergoing isolated CABG between 2002 and 2020, 242 patients had ESRD-HD with sinus rhythm. The primary outcome was a composite of death and stroke. An inverse probability (IP)-weighted cohort was created based on the propensity score. The 2 IP-weighted groups had well-balanced baseline and surgical backgrounds, with an equivalent follow-up. Five-year stroke-free survival was significantly higher in patients with LAA closure (log-rank test, P=0.035). The adjusted hazard ratio of LAA closure for death and stroke was 0.43 (95% confidence interval [CI] 0.20-0.92; P=0.023). Competing risk analysis showed that LAA closure was significantly associated with a risk reduction of stroke (subhazard ratio 0.26; 95% CI 0.08-0.96; P=0.028). No significant difference was observed in adjusted risk ratios for reoperation for bleeding, new atrial fibrillation, 30-day mortality, and readmission for heart failure.
Concomitant LAA closure during CABG can reduce the risk of death and stroke in ESRD-HD patients with normal sinus rhythm.
接受血液透析（ESRD-HD）的终末期肾病患者存在终生发生与心房颤动相关的中风的风险。我们比较了接受冠状动脉旁路移植术（CABG）的 ESRD-HD 患者与同时行左心耳（LAA）闭合术患者的临床结局。
在 2002 年至 2020 年间连续进行的 2783 例单纯 CABG 患者中，有 242 例 ESRD-HD 患者为窦性心律。主要结局是死亡和中风的复合事件。根据倾向评分创建了逆概率（IP）加权队列。2 个 IP 加权组的基线和手术背景均衡，随访时间相同。LAA 闭合患者的 5 年无中风生存率显著更高（对数秩检验，P=0.035）。LAA 闭合对死亡和中风的调整后的危险比为 0.43（95%置信区间 [CI]，0.20-0.92；P=0.023）。竞争风险分析表明，LAA 闭合与中风风险降低显著相关（亚危险比 0.26；95%CI 0.08-0.96；P=0.028）。对于出血、新发心房颤动、30 天死亡率和心力衰竭再入院的调整风险比，无显著差异。
在窦性心律的 ESRD-HD 患者中，CABG 时同时行 LAA 闭合可降低死亡和中风的风险。
