Surgical Snip Might Prevent Stroke in People With A-fib

By Steven Reinberg
HealthDay reporter

MONDAY, May 17, 2021 (HealthDay News) – Simple surgery can help reduce the risk of stroke by more than a third in patients with atrial fibrillation, a common irregular heartbeat, according to a new trial.

Reducing the risk of stroke is achieved by blocking the left atrial appendix, an unused finger-shaped tissue that traps blood in the upper chamber of the heart and increases the risk of clots that can cause strokes, have explained the researchers.

“This study was done in patients who were already undergoing heart surgery for other indications, so it was essentially the addition of a secondary procedure,” said lead investigator Dr. Richard Whitlock, professor. surgery at McMaster University in Hamilton, Ontario, Canada. .

As with most patients with atrial fibrillation, the patients in this study were already taking blood thinners to prevent strokes.

This study supports this procedure of removing and closing (occluding) the left atrial appendage during heart surgery. But patients will still need to take blood thinners after the operation, Whitlock noted.

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The combination of surgery and continuing to take blood thinners is how the extra protection against stroke is achieved, he added.

Removing the left atrial appendage does not affect the functioning of the heart and the procedure is safe and free of side effects, Whitlock said.

“This appendix is ​​left over from the way the heart forms when you develop in the womb,” he said. “It is not a vital factor, but it happens to be quite harmful when you develop atrial fibrillation.”

For the study, the researchers followed nearly 4,800 people in 27 countries who had atrial fibrillation and were taking blood thinners. They were on average 71 years old.

When these patients underwent heart bypass surgery, they were randomly selected to have their left atrial appendage removed or not. Patients were followed for a median of four years.

Dr. Gregg Fonarow, acting head of the cardiology division at the University of California at Los Angeles and director of the Ahmanson-UCLA Cardiomyopathy Center, believes this procedure is a breakthrough in the treatment of atrial fibrillation.

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“Atrial fibrillation is associated with a three to five-fold increased risk of stroke,” he said.

For patients undergoing heart surgery, removal of the left atrial appendage has been hypothesized to help reduce the risk of stroke, even among patients treated with blood thinners, Fonarow said.

Previously, however, no large-scale clinical trials have tested this hypothesis, and other studies have had mixed results. In addition, the guidelines did not provide definitive recommendations, he said.

This large trial provides convincing results that among atrial fibrillation patients undergoing heart surgery, removal of the left atrial appendage significantly reduces the risk of stroke when the majority continue to be treated with anticoagulants, said Fonarow.

“These results should change practice,” he said. “It is important to recognize that these results apply to surgical occlusion of the left atrial appendage when added to oral anticoagulation. [blood thinners]. Whether less invasive approaches for left atrial appendage removal are safe and effective when added to oral anticoagulation requires formal study. “

Whitlock agreed that it is not known whether this procedure will benefit patients with atrial fibrillation who have not previously had heart surgery.

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“This opens up a new paradigm that needs to be further investigated in non-cardiac operated patients, but it is a new paradigm of stroke prevention in atrial fibrillation,” he said.

Whitlock hopes trials will be done to see if the procedure reduces the risk of stroke in all patients with atrial fibrillation.

One expert, however, does not view these results as the end of the discussion about the benefits of the procedure.

“While I wouldn’t call this a breakthrough, it provides high quality data supporting the occlusion of the left atrial appendage at the time of cardiac surgery in patients with atrial fibrillation,” said Dr Larry Goldstein, chairman of the department of neurology at the University of Kentucky.

“It is important to note that the study does not support heart surgery for this purpose, and since it did not compare the removal of the left atrial appendage with anticoagulation alone, it did not determine so left atrial appendage surgery can replace oral anticoagulants, ”Goldstein mentioned.

The results of the study were published on May 15 in the New England Journal of Medicine, to coincide with a presentation at the American College of Cardiology Virtual Annual Meeting.

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More information

For more information on atrial fibrillation, see the American Heart Association.

SOURCES: Richard Whitlock, MD, PhD, professor, surgery, McMaster University, Hamilton, Ontario, Canada; Gregg Fonarow, MD, Acting Head, Division of Cardiology, University of California, Los Angeles, and Director, Ahmanson-UCLA Cardiomyopathy Center; Larry Goldstein, MD, professor and chair, department of neurology, University of Kentucky, Lexington; New England Journal of Medicine, May 15, 2021; American College of Cardiology Virtual Annual Meeting, Presentation, May 15, 2021

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