LAAOS III 2021 (Left Atrial Appendage Occlusion Study)


The LAAOS III trial found that surgical left atrial appendage closure during cardiac surgery was effective when used in conjunction with anticoagulation.


Description:


The study compared surgical left atrial appendage occlusion to no occlusion in patients with atrial fibrillation who were undergoing open-heart surgery for another reason.


Design of the Study:


Patients with atrial fibrillation and a high risk of stroke were randomized to surgical left atrial appendage occlusion (n = 2,379) or no left atrial appendage occlusion (n = 2,391) during open-heart surgery for another reason.


The total number of students enrolled: 4,770.

Follow-up time: 3.8 years.

The average patient: 71 years old.

32 percent of the population was female.

Diabetes: 32 percent of the population.


Criteria for inclusion:

  • People who are having heart surgery with cardiopulmonary bypass.
  • People who have atrial fibrillation and CHA2DS2-Vasc more than 2.


Criteria for exclusion:


  • Off-pump surgery 
  • Implantation of a mechanical valve
  • Transplantation of the heart
  • Complex congenital heart disease surgery
  • Implantation of a left ventricular assist device in a single patient
  • Previous pericardial surgery or implantation of a left atrial appendage occlusion device




The Most Important Findings:


At 3.8 years, the primary outcome of ischemic stroke or systemic embolism occurred in 4.8 percent of the occlusion group versus 7.0 percent in the non-occlusion group (p = 0.001).


2.2 percent of the occlusion group had an ischemic stroke or a systemic embolism within 30 days, compared to 2.7 percent of the non-occlusion group (p = not significant).


Ischemic stroke or systemic embolism lasting more than 30 days: 2.7 percent in the occlusion group vs. 4.6 percent in the control group (p = 0.001).


Secondary effects include:


Ischemic stroke: 4.6 percent in the occlusion group against 6.9% in the non-occlusion group (p 0.05).


Within 48 hours, 4.0 percent of the occlusion group required surgery, compared to 4.0 percent of the non-occlusion group.



Interpretation:


Left atrial appendage closure was preferable to no occlusion in patients with atrial fibrillation having cardiac surgery.


The majority of patients stayed on anticoagulant therapy for the rest of their lives (75 percent ).


At a mean of 3.8 years, closure of the left atrial appendage was linked to a significant reduction in ischemic stroke or systemic embolism.


When the outcomes were landmarked at 30 days versus less than 30 days, there was a greater benefit.


The treatment groups had equal levels of major hemorrhage.


The advantage of surgical left atrial appendage occlusion appears to be additive to anticoagulation medication; thus, this research does not support surgical left atrial appendage occlusion as an anticoagulant therapy replacement.


In 2021,  this is another important practice-changing trial that looked at ligating the left atrial appendage (LAA) in patients with atrial fibrillation undergoing surgery, which many cardiac surgeons have been performing. However, while the practice was logical, the facts supporting it were quite weak. 


LAAOS III demonstrated that surgical closure of the LAA using the surgeon's preferred method was extremely effective in preventing ischemic stroke or systemic embolism. 


Of course, barring contraindications, the vast majority of these patients should remain on long-term anticoagulation.

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