Endocardial left atrial appendage closure (LAAC) had a lower rate of complications and 30-day readmissions compared with epicardial LAAC, but higher hospitalization costs, likely due to the cost of the device involved, according to study results published in Heart Rhythm.

Researchers in this retrospective cohort study used 2016 data from 2 nationwide all-payer inpatient care claims databases for the Health care Cost and Utilization Project (HCUP) to report the national incidence for percutaneous LAAC (p-LAAC) to prevent stroke in patients with atrial fibrillation who are ineligible for long-term anticoagulation treatment, and to compare outcomes of endocardial LAAC with those of epicardial LAAC. Among 5480 p-LAACs, 5145 were endocardial and 335 were epicardial.

The overall in-hospital mortality for p-LAAC in the 5480 participants was 0.3%, with all 15 deaths occurring in endocardial LAAC patients. Endocardial LAAC had lower complications compared with epicardial LAAC (8.5% vs 25.4%; P <.001), and shorter length of stay (1 [IQR, 1-1] vs 2 [IQR, 1-3] day(s); P <.001), but higher hospitalization costs (24.13 [IQR, 18.45-30.17] vs 21.21 [IQR, 14.03-27.86] x 1000 dollars; P =.016).

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The higher cost for endocardial LAAC may have been partly due to the cost difference between the Watchman and Lariat devices. The lower rate of complications in endocardial LAAC compared with epicardial LAAC was driven by lower rates of cardiac complications (4.3% vs 16.4%; P <.001), and renal complications (1.8% vs 6.0%; P =.023). Epicardial LAAC had higher 30-day, unplanned, all-cause readmissions (19.5% vs 8.3%; P <.001) most commonly for pericarditis with or without pericardial effusion (33.92%).

This study was limited because of its reliance on claims data and the fact that the data presented were not contemporary. The implantation technique and postoperative care for epicardial LAAC has undergone many improvements since 2016, such as using a micro-puncture needle instead of a large-bore needle, which has reduced pericardial complications like severe pericarditis from 16% to 4%.

The study investigators concluded, “Endocardial LAAC performed at high volume centers (> 50/year) had the lowest in-hospital complications and 30-day readmissions at the expense of higher hospitalization costs. The most common in-hospital complications include pericardial-related, and [acute kidney injury] both higher with epicardial LAAC. Though epicardial cohort showed higher complications, given recent improvements in its technique, and postprocedural care demonstrated a significant reduction in pericardial complications. So contemporary data comparing these outcomes are needed. This will help us in building tools that can identify patients at high risk of complications or readmissions and thereby result in better patient selection and care transition for pLAAC.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Vuddanda VLK, Turagam MK, Umale NA, et al. Incidence and causes of in-hospital outcomes and 30-day readmissions after percutaneous left atrial appendage closure: a United States nationwide retrospective cohort study using claims data [published online September 17, 2019]. Heart Rhythm. doi:10.1016/j.hrthm.2019.09.018