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THE JOURNAL OF CARDIOVASCULAR SURGERY

A Journal on Cardiac, Vascular and Thoracic Surgery


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The Journal of Cardiovascular Surgery 2018 February;59(1):128-39

DOI: 10.23736/S0021-9509.17.09824-X

Copyright © 2017 EDIZIONI MINERVA MEDICA

language: English

Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials

Hasib HANIF 1, 2, Emilie P. BELLEY-COTE 1, Abdullah ALOTAIBI 1, 2, Nazari DVIRNIK 2, Binod NEUPANE 1, Joseph BEYENE 1, John W. EIKELBOOM 3, 4, David HOLMES 5, Richard P. WHITLOCK 1, 2, 4

1 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; 2 Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada; 3 Department of Medicine, McMaster University, Hamilton, ON, Canada; 4 Population Health Research Institute, Hamilton, ON, Canada; 5 Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN, USA


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INTRODUCTION: Atrial fibrillation (AF) is one of the leading causes of stroke. Risks associated with oral anticoagulation (OAC) limit adherence to recommended therapy. Left atrial appendage (LAA) occlusion is a treatment alternative in patients with AF. We performed a network meta-analysis (NMA) of randomized trials evaluating the efficacy of LAA occlusion compared with oral anticoagulant, antiplatelet, and placebo for stroke prevention. We also assessed the impact of LAA occlusion on mortality, major bleeding, and operative time.
EVIDENCE ACQUISITION: We searched MEDLINE, EMBASE, PubMed, and Cochrane Library for randomized trials comparing percutaneous or surgical LAA occlusion with standard of care in AF patients.
EVIDENCE SYNTHESIS: Conventional meta-analysis found no difference between groups for stroke (5 trials, 1285 patients;RR 0.78, 95% CI 0.47-1.29), and a significant reduction in mortality (5 trials, 1285 patients; RR 0.71, 95% CI 0.51-0.99) favouring LAA occlusion. NMA demonstrated a trend towards reduction in stroke (OR 0.84, 95% CrI 0.47-1.55) and mortality (OR 0.69, 95% CrI 0.44-1.10) for LAA occlusion versus warfarin, but no statistically significant effect. Statistical ranking curves placed LAA occlusion as the most efficacious treatment on the outcomes of stroke and mortality when compared to warfarin, aspirin, or placebo. No significant differences between groups were seen in major bleeding or operative time for surgical trials. The overall quality of the evidence was low as assessed by GRADE.
CONCLUSIONS: LAA occlusion appears to preserve the benefits of OAC therapy for stroke prevention in patients with AF, but the current evidence is of low quality.


KEY WORDS: Anticoagulants - Meta-analysis as topic - Warfarin - Stroke

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Publication History

Issue published online: November 28, 2017
Article first published online: February 17, 2017
Manuscript accepted: February 14, 2017
Manuscript revised: January 25, 2017
Manuscript received: December 5, 2016

Cite this article as

Hanif H, Belley-Cote EP, Alotaibi A, Dvirnik N, Neupane B, Beyene J, et al. Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials. J Cardiovasc Surg 2018;59:128-39. DOI:10.23736/S0021-9509.17.09824-X

Corresponding author e-mail

Richard.Whitlock@phri.ca