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  • Erica S. Zado
    Address reprint requests and correspondence: Ms Erica S. Zado, Cardiovascular Division, Founders 9, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104.
    Section of Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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      In this multicenter, randomized trial, Whitlock et al (N Engl J Med 2021;384:2081–2091; PMID 33999547) sought do determine whether surgical left atrial appendage occlusion (LAAO) prevents ischemic stroke in patients with atrial fibrillation (AF). Patients with AF and CHA2DS2-VASc score of at least 2 who were scheduled to undergo cardiac surgery were randomized on a 1:1 basis to surgical LAAO or no occlusion. The surgeon and surgical team were informed of the randomization, but teams taking care of the patient postoperatively, including during long-term follow-up and who were charged with managing anticoagulation, were blinded to the randomization, with surgical reports stating only that the patient was enrolled in a trial and may have undergone LAAO. During follow-up, the expectation was that patients would receive guideline-directed stroke prevention and usual care. Trial personnel contacted patients at 30 days and then every 6 months thereafter either in person or by telephone to determine anticoagulation use, administer a stroke symptom survey, and ask about cardiac events and hospitalizations. Records related to stroke symptoms and suspected embolic events were adjudicated by neurologists blinded to randomization. The preferred technique for LAAO was amputation and closure, but other techniques also were acceptable. The primary outcome was first occurrence of ischemic stroke, transient ischemic attack, or systemic embolism. Strokes of undetermined cause were included as ischemic strokes. Numerous secondary outcomes included procedural outcomes and complication measures, 30-day mortality, hospitalization for heart failure, and major bleeding.
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