Elsevier

The Annals of Thoracic Surgery

Volume 96, Issue 6, December 2013, Pages 2161-2167
The Annals of Thoracic Surgery

Original article
Adult cardiac
Preoperative Atrial Fibrillation Increases Risk of Thromboembolic Events After Left Ventricular Assist Device Implantation

Presented at the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013.
https://doi.org/10.1016/j.athoracsur.2013.07.004Get rights and content

Background

Because no series has specifically analyzed the impact of preoperative atrial fibrillation (AF) on patients already at higher risk of thromboembolism after implantation of a left ventricular assist device (LVAD), we review our experience with these patients.

Methods

Between July 2003 and September 2011, 389 patients (308 male) underwent implantation of a continuous flow LVAD at University of Michigan Hospital and Mayo Clinic. Median age at implant was 60 years (range, 18 to 79 years). Preoperative AF was present in 120 patients (31%). Outcomes were analyzed for the association of preoperative AF and postoperative thromboembolic (TE) events defined as stroke, transient ischemic attack, hemolysis, or pump thrombosis. Thromboembolic events occurring within the first 30 days were not counted.

Results

One hundred thirty-eight TEs events occurred in 97/389 patients (25%) for an event rate of 0.31 TE events/patient-years of support. Freedom from a TE event in patients with preoperative AF was 62% at 1 year and 46% at 2 years compared with 79% and 72% at 1 and 2 years, respectively, in patients without preoperative AF (p < 0.001). Median survival was 10 months (maximum 7.2 years, total 439 patient-years). Preoperative AF did not decrease late survival at 1 and 2 years after LVAD implant (preop AF: 85% and 70% versus no preop AF: 82% and 70%, respectively; p = 0.55).

Conclusions

Patients with preoperative AF have a lower freedom from TE events after LVAD implant. While overall late survival was not significantly reduced in these patients, refinement in anticoagulation strategies after VAD implant may be required.

Section snippets

Study Population

The data collection process and analysis was performed after informed patient consent and approved by the University of Michigan and Mayo Foundation Institutional Review Board. Between July 2003 and September 2011, 389 patients (308 men) underwent implantation of a continuous flow LVAD at University of Michigan Hospital and Mayo Clinic. Median age at implant was 60 years (range, 18 to 79 years); 95 patients were younger than 50 years, 232 were between 50 and 70 years, and 62 were older than 70

Results

Median follow-up was 10 months (maximum 7.2 years, total 439 patient-years) and was available in all early survivors (n = 365).

There were 138 TE events in 97 patients (25%; 97 of 389 patients); this was a single event in 66 patients (68%; 66 of 97 patients) and a multiple event in 31 patients (32%; 31 of 97 patients). Of the TE events, 49 were suspected or confirmed pump thrombus, 48 were hemolysis, 33 were stroke, and 8 were TIA; the overall rate of any TE event in this cohort was 0.31 per

Comment

We demonstrate in this study that preoperative AF in patients undergoing VAD implantation represents a significant risk factor for the development of TE events during follow-up. This finding was most significant for patients who were younger than 70 years at the time of implant. We observed that while both the incidence of preoperative AF and postoperative TE events increased with increasing age at implant, interestingly, increasing age was not an independent predictor of TE events. The

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