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. This is what a new study found.
Stroke risk reduction is achieved by blocking the left atrial appendage, an unused, finger-like tissue that traps blood in the upper chamber of the heart and increases the risk of blood clots that can cause strokes, the researchers explained.
“This study was done on patients who had already had heart surgery for other indications, so basically a secondary procedure was added,” said lead researcher Dr. Richard Whitlock, Professor of Surgery at McMaster University in Hamilton, Ontario, Canada.
As with most patients with atrial fibrillation, patients in this study were already taking blood thinners to prevent stroke.
This study supports this process of removal and occlusion of the left atrial appendage during heart surgery. According to Whitlock, patients will still need to take blood thinners after the operation.
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The combination of the surgery and continued use of blood thinners provides the additional protection against stroke, he added.
Removing the left atrial appendage doesn’t affect how the heart works, and the procedure is safe with no side effects, Whitlock said.
“That appendix is left over from how the heart forms when you develop in the womb,” he said. “It’s not a vital factor, but it is quite harmful if you develop atrial fibrillation.”
For the study, researchers tracked nearly 4,800 people in 27 countries who had atrial fibrillation and were taking blood thinners. They were 71 years old on average.
When these patients underwent cardiac bypass surgery, they were randomly selected to have their left atrial appendage removed or not. The patients were followed for a median of four years.
Dr. Gregg Fonarow, interim director of the Department of Cardiology 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 linked to a three to five-fold increased risk of stroke,” he said.
For patients with heart surgery, removing the left atrial appendage was thought to help lower the risk of stroke, even in patients treated with blood thinners, Fonarow said.
However, to date, no large-scale clinical studies have tested this hypothesis, and other studies have had mixed results. In addition, the guidelines did not provide final recommendations, he said.
This large study provides compelling results that in patients with atrial fibrillation undergoing heart surgery, removing the left atrial appendage significantly reduces the risk of stroke if the majority continue to be treated with blood thinners, Fonarow said.
“These results should change practice,” he said. “It is important to recognize that these results apply to left atrial appendage occlusion when added to oral anticoagulation [blood thinners]. Whether less invasive approaches to left atrial appendage removal are safe and effective when added to oral anticoagulation needs to be formally investigated. “
Whitlock agreed that it is unknown whether this procedure will benefit patients with atrial fibrillation who have not yet had heart surgery.
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“This opens up a new paradigm that needs further investigation in patients without cardiac surgery, but it is a new paradigm for stroke prevention in atrial fibrillation,” he said.
Whitlock hopes studies will be conducted to see if the procedure reduces the risk of stroke in all patients with atrial fibrillation.
However, one expert does not consider these results to be the end of the discussion of the usefulness of the procedure.
“While I wouldn’t call this a breakthrough, it does provide high quality data that supports left atrial appendage closure at the time of heart 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 cardiac surgery for this purpose. Since removal of the left atrial appendage was not compared to anticoagulation alone, it was not determined whether left atrial appendage surgery could replace oral blood thinners,” she said Goldstein said.
The study results were published in the New England Journal of Medicine on May 15, concurrently with a presentation at the American College of Cardiology’s annual virtual meeting.
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More information
For more information on atrial fibrillation, please contact the American Heart Association.
SOURCES: Richard Whitlock, MD, PhD, Professor, Surgery, McMaster University, Hamilton, Ontario, Canada; Gregg Fonarow, MD, interim chief, Department of Cardiology, University of California, Los Angeles, and director, Ahmanson-UCLA Cardiomyopathy Center; Larry Goldstein, MD, professor and chairman, Department of Neurology, University of Kentucky, Lexington; New England Journal of Medicine, May 15, 2021; American College of Cardiology Annual Virtual Meeting, presentation, May 15, 2021
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