Performing left atrial appendage occlusion (LAAO) at the same time as other cardiovascular interventions does not increase the patient’s risk of major adverse events, according to new research published in JACC: Cardiovascular Interventions.[1]
“In parallel with increased LAAO operator experience, there is a growing trend to combine clinically indicated procedures, especially those that share the intraprocedural imaging resources and/or procedural steps such as atrial fibrillation (AFib)/atrial flutter (AFL) ablation and transcatheter aortic valve replacement (TAVR),” wrote first author Mahmoud Ismayl, MD, a cardiology fellow with Mayo Clinic in Rochester, Minnesota, and colleagues. “Combined procedures may allow for fewer hospital visits, less exposure to the risks of anesthesia, vascular access, and imaging guidance and, ultimately, allow for a net improvement in patient safety and cost. Although combined procedures may represent an advancement in the field of LAAO, they are currently performed off-label, and data on their safety and efficacy remain limited.”
Ismayl et al. performed a retrospective study of nearly 89,000 U.S. hospitalizations from 2016 to 2020, including more than 1,200 that involved concomitant cardiac procedures. All data came from the National Inpatient Sample.
The most common procedure performed on the same day as LAAO was AFib/AFL ablation (73.2%), followed by TAVR (15.5%) and permanent pacemaker (PPM) insertion (6.9%). Other procedures combined with LAAO at least once included atrial septal defect (ASD) or patent foramen ovale (PFO) closure, transcatheter mitral valve replacement, percutaneous coronary intervention (PCI) and transcatheter edge-to-edge repair (TEER).
In addition to the group’s primary analysis, it also used propensity score matching to compare patients who underwent LAAO on its own with patients who underwent LAAO and a concomitant cardiac procedure in a 1:1 ratio. While propensity score matching helped ensure the two groups had similar baseline characteristics, the mean patient age was slightly younger among patients who underwent concomitant procedures (75 years old) than it was among patients who only underwent LAAO (77 years old).
Clinical outcomes from concomitant cardiac procedures
Overall, after making certain risk-based adjustments, LAAO patients who did and did not undergo concomitant cardiac procedures were associated with similar rates of major adverse cardiovascular events (MACEs), in-hospital mortality, stroke, acute kidney injury, major bleeding events, blood transfusions and vascular injuries. These findings were also true when the team ran its secondary analysis based on propensity matching.
Two differences in outcomes did stand out when the team presented its findings. First, performing LAAO and AFib/AFL ablation at the same time was linked to higher adjusted odds of heart block than performing LAAO alone. This was a “novel finding not previously reported,” the group explained, and the odds of other outcomes remained the same.
Second, performing LAAO and TAVR at the same time was linked to higher adjusted odds of stroke or vascular injury than performing LAAO alone.
“Increased stroke rates with concomitant TAVR may be attributed to the calcified valves involved, catheter manipulation, balloon valvuloplasty, and TAVR deployment,” the authors wrote. “The use of an additional access site with concomitant TAVR could potentially explain the higher vascular complications compared with isolated LAAO. Vascular injury is a known complication associated with TAVR.”
Healthcare costs and lengths of stay
Patients undergoing LAAO and an additional procedure were associated with much higher total costs than those who underwent just LAAO, as the researchers. On the other hand, it was much cheaper for patients to undergo LAAO and a concomitant cardiac procedure in the same hospitalization than to treat that patient twice in a relatively short period of time.
“Increased total costs would be expected when performing two procedures compared to one,” the authors wrote. “In addition, the complexity of combining two procedures in a single setting demands increased staff, experienced operators, and liability, all of which increase the burden on hospital resources. Restrictions in reimbursement are a main barrier to performing combined procedures in most Western countries.”
Ismayl and colleagues also found that performing concomitant cardiac procedures shortens the hospital length of stay (LOS). The median LOS was shorter when performing two same-day procedures at once than it was when performing two procedures on two different days.
The group concluded by emphasizing that more research is still needed, including “randomized trials with long-term follow-up.”
Additional context from Samir Kapadia
Cleveland Clinic’s Samir Kapadia, MD, spoke with Cardiovascular Business at TCT 2023 in San Francisco about the possibilities of performing multiple cardiac procedures at once. He presented positive data from the WATCH-TAVR trial, which focused on outcomes after performing a Watchman LAAO and TAVR at the same time, and said he expect cardiologists to push for combining cardiac procedures much more in the next few years.
“There are so many things that are complimentary in the same patients, and this trial shows that we can do it relatively safely together,” he said. “I think there is a good chance that we can potentially make this a reality.”
Click here to read more about WATCH-TAVR and Kapadia’s perspective on this evolving trend.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.