Noona Sean W W, Young Steven D, Weber Matthew P, El Moheb Mohamad, Norman Anthony V, Wisniewski Alex M, Strobel Raymond J, Quader Mohammed, Mazzeffi Michael A, Yarboro Leora T, Beller Jared P, Teman Nicholas R
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
J Thorac Cardiovasc Surg. 2024 Aug 15. doi: 10.1016/j.jtcvs.2024.08.004.
The study objective was to evaluate short-term outcomes and statewide practice patterns of prophylactic left atrial appendage ligation in patients undergoing coronary artery bypass grafting without preoperative atrial fibrillation.
Adult patients who underwent on-pump coronary artery bypass grafting (2017-2023) within a regional collaborative were identified. Patients with a history of atrial fibrillation, previous cardiac surgery, or nondevice-based left atrial appendage ligation were excluded. Patients were stratified by left atrial appendage ligation status and were propensity score matched. Univariable analysis was used to compare short-term clinical outcomes.
Of 16,547 patients examined, 442 underwent prophylactic left atrial appendage ligation. The propensity score-matched cohort (439 in the prophylactic left atrial appendage ligation group, 439 in the no prophylactic left atrial appendage ligation group) was compared and had no significant differences in preoperative Congestive heart failure, Hypertension, Age ≥ 75 (doubled), Diabetes mellitus, prior Stroke, Transient ischemic attack or Thromboembolism (doubled), Vascular disease, Age 65 to 74, Sex category (female)(CHADS-VASc) scores or operative variables. The prophylactic left atrial appendage ligation group had longer crossclamp time (82 vs 76 minutes, P = .001), intensive care unit hours (72 vs 66, P = .001), and length of stay (6.0 vs 6.0 days, P = .010); increased postoperative atrial fibrillation (35% vs 24%, P < .001); and more discharges on anticoagulation (17% vs 8.2%, P < .001). There were no significant differences in postoperative stroke (1.1% vs 2.1%, P = .423), readmission (13% vs 9.6%, P = .118), operative mortality (2.5% vs 1.6%, P = .480), or readmission for thrombotic or bleeding complications (0.7% vs 1.1%, P = .724). Hospitalization costs were significantly higher for the prophylactic left atrial appendage ligation group ($43,478 vs $40,645, P < .001). The rate of prophylactic left atrial appendage ligation during coronary artery bypass grafting increased from 1.61% (2017) to 5.65% (2023) (P < .001).
Despite higher rates of postoperative atrial fibrillation, discharge on anticoagulation, and hospitalization costs in patients undergoing prophylactic left atrial appendage ligation during coronary artery bypass grafting, there was no difference in short-term clinical end points including stroke and operative mortality.
本研究的目的是评估在无术前房颤的冠状动脉旁路移植术患者中预防性左心耳结扎的短期结局及全州范围内的实践模式。
确定在区域协作范围内接受体外循环冠状动脉旁路移植术（2017 - 2023年）的成年患者。排除有房颤病史、既往心脏手术史或非器械辅助左心耳结扎的患者。根据左心耳结扎状态对患者进行分层，并进行倾向评分匹配。采用单变量分析比较短期临床结局。
在16547例接受检查的患者中，442例接受了预防性左心耳结扎。对倾向评分匹配的队列（预防性左心耳结扎组439例，非预防性左心耳结扎组439例）进行比较，两组在术前充血性心力衰竭、高血压、年龄≥75岁（翻倍）、糖尿病、既往卒中、短暂性脑缺血发作或血栓栓塞（翻倍）、血管疾病、年龄65至74岁、性别类别（女性）（CHADS - VASc）评分或手术变量方面无显著差异。预防性左心耳结扎组的主动脉阻断时间更长（82分钟对76分钟，P = 0.001）、重症监护病房时长更长（72小时对66小时，P = 0.001）、住院时间更长（6.0天对6.0天，P = 0.010）；术后房颤发生率更高（35%对24%，P < 0.001）；抗凝出院率更高（17%对8.2%，P < 0.001）。术后卒中（1.1%对2.1%，P = 0.423）、再入院率（13%对9.6%，P = 0.118）、手术死亡率（2.5%对1.6%，P = 0.480）或因血栓形成或出血并发症再入院率（0.7%对1.1%，P = 0.724）无显著差异。预防性左心耳结扎组的住院费用显著更高（43478美元对40645美元，P < 0.001）。冠状动脉旁路移植术中预防性左心耳结扎率从2017年的1.61%增至2023年的5.65%（P < 0.001）。
尽管在冠状动脉旁路移植术中接受预防性左心耳结扎的患者术后房颤发生率、抗凝出院率和住院费用更高，但在包括卒中和手术死亡率在内的短期临床终点方面并无差异。
