Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke

Objective: Left atrial appendage closure (LAAC) concomitant to heart surgery in patients with underlying atrial fibrillation (AF) has gained attention because of long-term reduction of thromboembolic complications. As of mortality benefits in the setting of non-AF, data from both observational studies and randomized controlled trials are conflicting. Methods: On-line databases were screened for studies comparing LAAC versus no LAAC concomitant to other heart surgery. End points assessed were all-cause mortality and stroke at early and longest-available follow-up. Subgroup analyses stratified on preoperative AF were performed. Risk ratios (RR) with 95% CIs served as primary statistics. Results: Electronic search yielded 25 studies (N = 660 [158 patients]). There was no difference between LAAC and no LAAC in terms of early mortality. In the overall population analysis, LAAC reduced long-term mortality (RR, 0.86; 95% CI, 0.74-1.00; P =.05; I2 = 88%), reduced early stroke risk by 19% (RR, 0.81; 95% CI, 0.72-0.93; P =.002; I2 = 57%), and reduced late stroke risk by 13% (RR, 0.87; 95% CI, 0.84-0.90; P <.001; I2 = 58%). Subgroup analysis showed lower mortality (RR, 0.85; 95% CI, 0.72-1.01; P =.06; I2 = 91%), short-, and long-term stroke risk reduction only in patients with preoperative AF (RR, 0.81; 95% CI, 0.71-0.93; P =.003; I2 = 71% and RR, 0.87; 95% CI, 0.84-0.91; P <.001; I2 = 70%, respectively). No benefit of LAAC in patients without AF was found. Conclusions: Concomitant LAAC was associated with reduced stroke rates at early and long-term and possibly reduced all-cause mortality at the long-term follow-up but the benefits were limited to patients with preoperative AF. There is not enough evidence to support routine concomitant LAAC in non-AF settings.