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Original research
Exclusion versus preservation of the left atrial appendage in rheumatic mitral valve surgery
  1. Wan Kee Kim1,
  2. Ho Jin Kim2,
  3. Joon Bum Kim2,
  4. Sung Ho Jung2,
  5. Suk Jung Choo2,
  6. Cheol Hyun Chung2,
  7. Jae Won Lee2
  1. 1Cardiothoracic Surgery, Yonsei University Medical Center, Yongin, South Korea
  2. 2Cardiothoracic Surgery, Asan Medical Center, Songpa-gu, South Korea
  1. Correspondence to Dr Joon Bum Kim, Cardiothoracic Surgery, Asan Medical Center, Songpa-gu 138-736, South Korea; jbkim1975{at}


Objectives This study aimed to evaluate the impact of left atrial appendage exclusion on clinical outcomes in patients with atrial fibrillation (AF) undergoing rheumatic mitral surgery.

Methods We retrospectively reviewed 1226 consecutive patients with AF (54.5±11.6 years; 68.2% females) who underwent rheumatic mitral valve (MV) surgery from 1997 to 2016. The left atrial appendage was preserved in 836 (68.2%) and excluded in 390 (31.8%) patients. Surgical AF ablation was performed in 506 (60.5%) and 304 (77.9%) patients with preserved and excluded left atrial appendage, respectively. For baseline adjustment, propensity matching was used.

Results During a median follow-up of 63.4 months (IQRs, 20–111 months), there were no significant intergroup differences in the risks of mortality (2.77% vs 3.03%/patient-years) and thromboembolic events (0.91% vs 1.02%/patient-years). In the 258 pairs of propensity-score matched patients, death (2.77% vs 3.03%/patient-years) and thromboembolism (1.36% vs 0.82%/patient-years) outcomes were comparable for both groups. In a subgroup undergoing ablation (n=810), there were no significant differences in the adjusted risks of death (HR, 0.67; 95% CI, 0.34 to 1.32) and thromboembolism (HR, 0.47; 95% CI, 0.18 to 1.26). In a subgroup not undergoing ablation (n=416), however, left atrial appendage preservation tended to have higher adjusted risks for death (HR, 2.24; 95% CI, 0.98 to 5.13) and thromboembolism (HR, 4.41; 95% CI, 0.97 to 20.1).

Conclusions Left atrial appendage preservation did not seem to have greater risks of adverse clinical events in patients with AF undergoing rheumatic MV surgery particularly when ablation procedure is combined.

  • stroke
  • atrial fibrillation
  • atrial arrhythmia ablation procedures
  • mitral stenosis

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  • Collaborators Seon Ok Kim; Sung-Cheol Yun.

  • Contributors JBK conceived the present study. JBK and WKK performed statistical analyses. JBK and JWL handled funding and supervision. WKK, HJK, SHJ, SJC and CHC acquired the data of present study. WKK drafted the manuscript. JBK made critical revision of the manuscript for key intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The study protocol was approved by the Institutional Review Board of the Asan Medical Center (2016-0862). The requirement for informed consent from individual patients was waived due to the retrospective nature of the study design.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

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