心脏手术患者无房颤时预防性左心耳封堵预防中风：随机和倾向评分研究的荟萃分析。

Stroke Prevention With Prophylactic Left Atrial Appendage Occlusion in Cardiac Surgery Patients Without Atrial Fibrillation: A Meta-Analysis of Randomized and Propensity-Score Studies.

机构信息

Department of Cardiac Surgery Research (M.B., S.S., Y.Y., M.S., B.R.), Lankenau Heart Institute, Main Line Health, Wynnewood, PA.

Lankenau Institute for Medical Research, and Department of Cardiac Surgery (Y.Y., B.R.), Lankenau Heart Institute, Main Line Health, Wynnewood, PA.

出版信息

Circ Cardiovasc Interv. 2024 Oct;17(10):e014296. doi: 10.1161/CIRCINTERVENTIONS.124.014296. Epub 2024 Sep 11.

DOI:10.1161/CIRCINTERVENTIONS.124.014296

PMID:39258365

Abstract

BACKGROUND

The role of left atrial appendage occlusion (LAAO) in patients without previous atrial fibrillation (AF) is not established. This meta-analysis was conducted on patients with normal sinus rhythm who underwent cardiac surgery, with and without concomitant LAAO, to evaluate its effect on the incidence of cerebrovascular accidents (CVAs).

METHODS

A systematic review was conducted from inception until December 2023 for randomized and propensity-score studies comparing CVA in patients without AF undergoing cardiac surgery with or without LAAO.

RESULTS

Six studies met our inclusion criteria with a total of 4130 patients: 2146 in the LAAO group and 1984 in the no-LAAO group. The risk ratio of postoperative AF was 1.05 (95% CI, 0.86-1.28); =0.628. The CVA rates at 5 years were 6.8±1.0% in the no-LAAO group and 4.3±0.8% in the LAAO group (log-rank =0.021). The Cox regression analysis for CVA in patients undergoing LAAO reported a hazard ratio of 0.65 (95% CI, 0.45-0.94); =0.022. Landmark analysis at 4 years highlighted a significant difference in overall survival between no-LAAO and LAAO groups, 86±12.2% versus 89.6±11.0%; =0.041.

CONCLUSIONS

In this meta-analysis of patients without previous AF undergoing cardiac surgery, LAAO was associated with a decreased risk of CVA, no difference in the incidence of postoperative atrial fibrillation, and a significant overall survival benefit at a 4-year landmark analysis. Although these findings support LAAO, the randomized LeAAPS trial (Left Atrial Appendage Exclusion for Prophylactic Stroke Reduction Trial), LAA-CLOSURE trial (A Randomized Prospective Multicenter Trial for Stroke Prevention by Prophylactic Surgical Closure of the Left Atrial Appendage in Patients Undergoing Bioprosthetic Aortic Valve Surgery), and LAACS-2 trial (Left Atrial Appendage Closure by Surgery-2) will help define the effectiveness of LAAO in patients undergoing cardiac surgery who have risk factors for AF and CVA.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42024496366.

摘要

背景

左心耳封堵术（LAAO）在既往无房颤（AF）患者中的作用尚未确定。本荟萃分析对接受心脏手术且伴有或不伴有同期 LAAO 的窦性节律患者进行，旨在评估其对脑血管意外（CVA）发生率的影响。

方法

系统检索自成立至 2023 年 12 月的随机和倾向评分研究，比较了无 AF 行心脏手术患者伴或不伴 LAAO 的 CVA 发生率。

结果

6 项研究符合纳入标准，共纳入 4130 例患者：LAAO 组 2146 例，无 LAAO 组 1984 例。术后房颤的风险比为 1.05（95%CI，0.86-1.28）；=0.628。无 LAAO 组 5 年 CVA 发生率为 6.8±1.0%，LAAO 组为 4.3±0.8%（log-rank =0.021）。LAAO 患者 CVA 的 Cox 回归分析报告风险比为 0.65（95%CI，0.45-0.94）；=0.022。4 年的里程碑分析显示，无 LAAO 和 LAAO 组之间的总生存存在显著差异，分别为 86±12.2%和 89.6±11.0%；=0.041。

结论

在本荟萃分析中，既往无 AF 行心脏手术的患者中，LAAO 与 CVA 风险降低相关，术后房颤发生率无差异，4 年里程碑分析显示总生存有显著获益。尽管这些发现支持 LAAO，但 LeAAPS 试验（左心耳封堵预防卒中减少试验）、LAA-CLOSURE 试验（生物瓣主动脉瓣置换术患者预防性外科封堵左心耳预防卒中的前瞻性多中心随机试验）和 LAACS-2 试验（左心耳外科封堵-2 试验）将有助于确定心脏手术中存在 AF 和 CVA 风险因素的患者中 LAAO 的有效性。