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SAN ANTONIO -- The Society of Thoracic Surgeons (STS) made a big push for left atrial appendage (LAA) occlusion in updated guidelines for the surgical treatment of atrial fibrillation (Afib).

In this document, concomitant LAA occlusion jumped to the highest-level recommendation (class I-A) during all first-time non-emergent cardiac surgery. This procedure had previously sat at a weaker class IIa-C endorsement in the 2017 guideline, according to co-author Moritz Wyler von Ballmoos, MD, PhD, of Texas Health Fort Worth, who introduced the new 2023 recommendations to a packed room here at the STS annual meeting. The guideline was published in the .

Wyler von Ballmoos attributed the new enthusiasm for concomitant LAA occlusion to LAAOS III, a randomized trial that showed that this additional surgery cut strokes and systemic embolisms by 33% on top of oral anticoagulation, and with no evidence of adverse effects in Afib patients already undergoing cardiac surgery for another indication.

"All patients that are undergoing surgery with [Afib] should have their appendage closed. If we don't take anything else away from the STS this year, this should be it. It's kind of amazing that about 60% of the patients with Afib don't even have their [LAA] closed," said Patrick McCarthy, MD, of Northwestern Medicine in Chicago, during the session.

McCarthy told the audience that it takes him just 86 seconds to perform an LAA occlusion.

"It's over 35 years ago now, was the first Maze and it's over 20 years since we've had bipolar radiofrequency. It time to sort of reboot how we look at concomitant Afib surgery," McCarthy stressed. "Add ablation whenever possible, and then use the technology and the lesions that you are comfortable with, and if you're not, then go learn something new."

Standalone surgical LAA obliteration is also mentioned for the first time in this edition of the STS guidelines, earning a "may be considered" rating for people with longstanding persistent Afib, high stroke risk, and not able to tolerate long-term oral anticoagulation (class IIb-B). Due to the reliance on observational data, however, Wyler von Ballmoos urged the generation of randomized data comparing surgical standalone LAA occlusion versus percutaneous or medical therapy alone.

LAAOS III investigator Richard Whitlock, MD, PhD, of McMaster University in Hamilton, Ontario, called concomitant LAA surgery "the gift to your patient that keeps on giving" but acknowledged that operators should probably not do this procedure on just anybody, Afib or not.

Whitlock described his group's ongoing trial that plans to have 6,500 patients with atrial cardiomyopathy factors -- not yet diagnosed with Afib -- randomized to get an additional AtriClip procedure or have their scheduled cardiac surgery alone. The hope is to show a reduction in stroke or systemic embolism even as both groups continue oral anticoagulation as per guidelines, he said.

Outside LAA surgery, Wyler von Ballmoos also provided an overview of other notable recommendations in the latest STS guidelines on Afib.

Concomitant surgical ablation for Afib during mitral operations keeps its class I-A rating due to long-term safety and benefits. Outside mitral valve surgery, concomitant surgical ablation has its class I-B recommendation extended to all first-time non-emergent surgeries, not just the aortic valve replacement and coronary artery bypass graft operations explicitly mentioned in the 2017 document.

Wyler von Ballmoos noted that this stance of the STS differs markedly from that of the American Heart Association and American College of Cardiology, which have concomitant surgical ablation downgraded in their 2023 guideline.

Additionally, for STS, standalone surgical ablation, using the Cox-Maze III/IV lesions set or not, is considered reasonable (class IIa-B) to restore sinus rhythm for symptomatic Afib in the absence of structural heart disease. However, in the setting of left atrial enlargement or more than moderate mitral regurgitation, surgical ablation by pulmonary vein isolation alone is not recommended (class III-C).