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. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: Am J Cardiol. 2020 Apr 7;126:106–107. doi: 10.1016/j.amjcard.2020.03.049

Reader’s Comments: Trends in the Utilization of Left Atrial Appendage Exclusion in the United States

Safi U Khan a, Muhammad Zia Khan a, Mohamad Alkhouli b
PMCID: PMC7397545  NIHMSID: NIHMS1612670  PMID: 32336535

Stroke prevention remains a cornerstone in the management of patients with nonvalvular atrial fibrillation (NVAF).1 Oral anticoagulation is the main method of stroke prevention in NVAF world-wide. However, >50% of high-risk NVAF patients are not maintained on oral anticoagulation due to comorbidities, frailty, bleeding complications, or noncompliance.2 In 1996, Blackshear proposed left atrial appendage exclusion (LAAE) as an alternative stroke prevention strategy in NVAF.3 Because no randomized data were available to support the routine use of LAAE, its utilization remained initially limited to selected patients undergoing a concomitant cardiac surgery. In 2001, Sievert performed the first percutaneous LAAE using the Percutaneous Left Atrial Appendage Transcatheter Occlusion device.4 Since then, an affluence of observational studies supporting the utility of both percutaneous and surgical LAAE emerged but randomized data remained limited.2,4–8 Despite that, both surgical and percutaneous LAAE procedures appear to be increasingly utilized in the United States, but data on those utilization patterns are lacking. Herein, we studied a nation-level database to illustrate trends of surgical and transcatheter LAAE procedures and demographic and clinical profile of patients undergoing these procedures.

The National-Inpatient-Sample was used to select patients who underwent LAAE between January 1, 2008 and December 31, 2017. The National-Inpatient-Sample is a publicly available claims-based database that contains data on discharges from ~1,000 non-federal hospitals in 45 states.9 The outcomes of interest were the annual trends in surgical and percutaneous LAAE, and the clinical profile of patients undergoing these procedures. Linear regression was used for analyzing trends over years. Categorical variables were compared using a Pearson chi-square test and Fisher’s exact test and continuous variables were compared using independent samples t test. Weighted national estimated were used for the analysis. All analyses were performed using SPSS V-26.

Among 208,096 patients who underwent LAAE between 2008 and 2017, 186,491 (89.6%) had surgical LAAE and 21,605 (10.4%) had transcatheter LAAE. The utilization of LAAE increased 17 folds from 2,479 cases in 2008 to 43,050 in 2017 (Ptrend <0.001) (Figure 1). The majority (96.0%) of surgical LAAE were performed with a concomitant major cardiac surgery procedure. The most common concomitant surgery was mitral valve surgery (61.0%). Concomitant surgical ablation of atrial fibrillation (MAZE procedure) was performed in 23.9%.

Figure 1.

Figure 1.

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Trends in left atrial appendage exclusion procedures in United States.

Compared with patients undergoing surgical LAAE, those who had percutaneous LAAE were older (74.7 ± 8.8 vs 68.25 ± 11.0, p <0.01), had more females (39.8% vs 36.8%, p <0.001), and more patients of White race (85.8% vs 82.7%, p <0.001). They also had higher prevalence of prior stroke (7.9% vs 7.5%, p = 0.02), coronary disease (61.5% vs 47.8%, p <0.001) renal insufficiency (20.1% vs 17.8%, p <0.001), and heart failure (45.9% vs 32.2%, p <0.001). The mean CHADS2VASC score was 3.41 ± 1.25 in the percutaneous LAAE group and 3.07 ± 1.52 in the surgical LAAE group.

This focused analysis documents a substantial increase in the utilization LAAE procedures in the United States. More randomized data are needed to assess the efficacy of LAAE as a stroke prevention strategy in patients with NVAF in contemporary practice.

Footnotes

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References

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