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Radakovic D, Penov K, Lazarus M, Madrahimov N, Hamouda K, Schimmer C, Leyh RG, Bening C. The completeness of the left atrial appendage amputation during routine cardiac surgery. BMC Cardiovasc Disord 2023; 23:308. [PMID: 37340354 DOI: 10.1186/s12872-023-03330-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/03/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Left atrial appendage (LAA) is the origin of most heart thrombi which can lead to stroke or other cerebrovascular event in patients with non-valvular atrial fibrillation (AF). This study aimed to prove safety and low complication rate of surgical LAA amputation using cut and sew technique with control of its effectiveness. METHODS 303 patients who have undergone selective LAA amputation were enrolled in the study in a period from 10/17 to 08/20. The LAA amputation was performed concomitant to routine cardiac surgery on cardiopulmonary bypass with cardiac arrest with or without previous history of AF. The operative and clinical data were evaluated. Extent of LAA amputation was examined intraoperatively by transoesophageal echocardiography (TEE). Six months in follow up, the patients were controlled regarding clinical status and episodes of strokes. RESULTS Average age of study population was 69.9 ± 19.2 and 81.9% of patients were male. In only three patients was residual stump after LAA amputation larger than 1 cm with average stump size 0.28 ± 0.34 cm. 3 patients (1%) developed postoperative bleeding. Postoperatively 77 (25.4%) patients developed postoperative AF (POAF), of which 29 (9.6%) still had AF at discharge. On 6 months follow up only 5 patients had NYHA class III and 1 NYHA class IV. Seven patients reported with leg oedema and no patient experienced any cerebrovascular event in early postoperative follow up. CONCLUSION LAA amputation can be performed safely and completely leaving minimal to no LAA residual stump.
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Affiliation(s)
- Dejan Radakovic
- Department of Thoracic and Cardiovascular Surgery, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany.
| | - Kiril Penov
- Department of Thoracic and Cardiovascular Surgery, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Marc Lazarus
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Nodir Madrahimov
- Department of Thoracic and Cardiovascular Surgery, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Khaled Hamouda
- Department of Thoracic and Cardiovascular Surgery, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Christoph Schimmer
- Department of Thoracic and Cardiovascular Surgery, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Rainer G Leyh
- Department of Thoracic and Cardiovascular Surgery, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Constanze Bening
- Department of Thoracic and Cardiovascular Surgery, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
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Sakatani Y, Ito T, Hasegawa H, Akamatsu K, Hoshiga M. Left Atrial Appendage Ostial Stenosis: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930510. [PMID: 33833212 PMCID: PMC8045559 DOI: 10.12659/ajcr.930510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Patient: Female, 34-year-old Final Diagnosis: Left atrial appendage ostial stenosis Symptoms: No symptoms Medication:— Clinical Procedure: — Specialty: Cardiology
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Affiliation(s)
- Yuka Sakatani
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Takahide Ito
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Hitomi Hasegawa
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kanako Akamatsu
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
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Salzberg SP, Emmert MY, Caliskan E. Surgical techniques for left atrial appendage exclusion. Herzschrittmacherther Elektrophysiol 2017; 28:360-365. [PMID: 29150698 DOI: 10.1007/s00399-017-0532-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
The increasing prevalence of atrial fibrillation with the aging population and its associated major morbidity and mortality due to thromboembolic stroke have resulted in intensive research on stroke prevention or stroke risk reduction strategies. Several surgical techniques for left atrial appendage (LAA) occlusion have evolved over the past decades. Surgeons have been using different techniques leading to highly variable and, in particular, poor data on outcomes. LAA closure is performed either as a concomitant procedure during open-heart surgery or as a stand-alone surgical procedure as part of minimally invasive (mini-thoracotomy or thoracoscopy) arrhythmia surgery. Data on the safety and feasibility of surgical LAA occlusion are derived mainly from nonrandomized case series, observational and cohort studies, or registries with mostly inconclusive and conflicting results. Increased awareness of the high failure rates in attaining complete LAA occlusion, thus avoiding poor surgical techniques (e. g., simple suture ligation, endocardial suturing etc.), and the availability of newer devices (e. g., AtriClip device) have recently led to improved surgical results in the literature. If further validated in large-scale studies, these recent promising developments in the field of surgical LAA treatment seem to offer alternatives for patients ineligible for oral anticoagulation therapy with vitamin K antagonists or newer non-vitamin-K-dependent oral anticoagulants.
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Affiliation(s)
- Sacha P Salzberg
- HeartClinic, Hirslanden Hospital, Witellikerstraße 40, 8032, Zurich, Switzerland.
| | - Maximilian Y Emmert
- Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Raemistraße 100, 8091, Zurich, Switzerland
| | - Etem Caliskan
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Caliskan E, Cox JL, Holmes DR, Meier B, Lakkireddy DR, Falk V, Salzberg SP, Emmert MY. Interventional and surgical occlusion of the left atrial appendage. Nat Rev Cardiol 2017; 14:727-743. [DOI: 10.1038/nrcardio.2017.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Complete Obliteration of the Left Atrial Appendage: An Analysis of Epicardial Excision and Novel Pericardial Patch Exclusion. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:282-7. [PMID: 27571564 DOI: 10.1097/imi.0000000000000281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Conventional epicardial excision is believed to be the most effective method of surgically obliterating the left atrial appendage (LAA), although incomplete resection and residual LAA volume may undermine its effectiveness. We sought to compare the impact of conventional epicardial excision with a novel LAA pericardial patch exclusion on residual LAA volume. METHODS We performed LAA obliteration using pericardial patch exclusion, followed by conventional epicardial excision, in 27 cadaveric hearts. After each procedure, residual LAA volume was measured by two different techniques and compared with baseline volume. There was no difference in baseline LAA volume between each procedure. RESULTS Procedural success was achieved in all hearts. Conventional epicardial excision left a residual LAA volume of 0.95 mL (24%), as compared with pericardial patch exclusion, which left a residual volume of 0.17 mL (4%, P = 0.0001). Further analysis of fixed and fresh hearts showed that reduction of LAA volume was more pronounced in the fresh hearts, suggesting effectiveness in live patients. Neither technique resulted in any significant change in the endocardial shape of the LAA orifice or injury to the circumflex artery. CONCLUSIONS Conventional epicardial excision of the LAA results in significantly more residual LAA volume, which may have important implications in persistent stroke risk. Pericardial patch exclusion seems to achieve near-total elimination of the LAA and may be a superior surgical option.
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Malakouti-Nejad BB, Winkler EJ, Johnson MI, Catrip J, Losenno KL, Kiaii BB, Chu MWA. Complete Obliteration of the Left Atrial Appendage an Analysis of Epicardial Excision and Novel Pericardial Patch Exclusion. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Eliot J. Winkler
- Department of Anatomy and Cell Biology, University of Western Ontario, London, Ontario, Canada
| | - Marjorie I. Johnson
- Department of Anatomy and Cell Biology, University of Western Ontario, London, Ontario, Canada
| | - Jorge Catrip
- Division of Cardiac Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Katie L. Losenno
- Division of Cardiac Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Bob B. Kiaii
- Division of Cardiac Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Michael W. A. Chu
- Department of Anatomy and Cell Biology, University of Western Ontario, London, Ontario, Canada
- Division of Cardiac Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
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Lanigan MJ, Chaney MA, Nathan S, Shah AP, Feider AJ. Case 4-2015: use of the lariat device for left atrial appendage closure. J Cardiothorac Vasc Anesth 2016; 29:522-31. [PMID: 25791690 DOI: 10.1053/j.jvca.2014.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL.
| | - Sandeep Nathan
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, Chicago, IL
| | - Atman P Shah
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, Chicago, IL
| | - Andrew J Feider
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine
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8
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Min X, Zhu T, Han J, Li Y, Meng X. Left atrial appendage obliteration in atrial fibrillation patients undergoing bioprosthetic mitral valve replacement. Herz 2015; 41:87-94. [DOI: 10.1007/s00059-015-4350-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/26/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022]
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Abo-Salem E, Lockwood D, Boersma L, Deneke T, Pison L, Paone RF, Nugent KM. Surgical Treatment of Atrial Fibrillation. J Cardiovasc Electrophysiol 2015; 26:1027-1037. [PMID: 26075595 DOI: 10.1111/jce.12731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/25/2015] [Accepted: 05/27/2015] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is the most common chronic arrhythmia in the adult population. Ablation lines have largely replaced the historical and challenging cut and sew techniques. Surgical ablation of AF is commonly performed in cases with other indications for cardiac surgery and less commonly as a stand-alone therapy. Pulmonary vein isolation is the cornerstone of this procedure. Extended left atrial ablation lines may increase efficacy in cases with longstanding persistent or permanent AF. Additional efficacy by adding right atrial ablation is controversial but is often performed in cases undergoing right atrial or atrial septal surgery. Left atrial volume reduction is recommended in cases with large left atria and AF undergoing another cardiac surgery. Arrhythmia recurrence is not uncommon after surgical ablation of AF and varies among studies due to heterogeneity in patient population, lesion set and endpoints. Freedom from AF recurrence was 65-87% at 12 months and 58-70% at 2 years follow-up. Long-term monitoring is recommended due to an increased prevalence of asymptomatic recurrences. The strongest predictors of AF recurrence are longstanding or persistent AF and a large left atrium. The most common mechanisms of recurrence are pulmonary vein reconnection, nonpulmonary vein triggers, and gaps in the ablation lines. About 20% of atrial tachyarrhythmia recurrences are atrial flutter or atrial tachycardia. There are not enough data in the surgical literature to support withdrawal of anticoagulation after surgical AF ablation. Patients selected for stand-alone surgical ablation usually have low risk profiles and low postoperative mortality rates (0.2%).
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Affiliation(s)
- Elsayed Abo-Salem
- Division of Cardiovascular Health and Diseases, University of Cincinnati, Cincinnati, Ohio
| | - Deborah Lockwood
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Thomas Deneke
- Department of Cardiology, BG-Kliniken Bergmannsheil, University of Bochum, Bochum, Germany
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ralph F Paone
- Department of Surgery, Texas Tech University HSC, Lubbock, Texas, USA
| | - Kenneth M Nugent
- Division of Pulmonary and Critical Care Medicine, Texas Tech University HSC, Lubbock, Texas, USA
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Guerrero M, Greenbaum A, O’Neill W. First-in-man late partial recanalisation after LARIAT suturing of the left atrial appendage successfully treated with an AMPLATZERª septal occluder device. EUROINTERVENTION 2015; 10:1126. [DOI: 10.4244/eijy14m07_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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11
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Turi ZG. Clinical Results with Percutaneous Left Atrial Appendage Occlusion. Interv Cardiol Clin 2014; 3:291-300. [PMID: 28582172 DOI: 10.1016/j.iccl.2014.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Closure of the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation is associated with reduction in embolic events. There is an initial hazard associated with closure methodologies; once successful closure is achieved, the results appear to be superior to those of anticoagulation. The evidence base is largely limited to the safety and efficacy of LAA occlusion in patients who are candidates for anticoagulation as well, and the risk/benefit ratio of competing closure technologies has not been determined. LAA occlusion plus antiplatelet therapy seems to have an acceptable therapeutic and safety profile.
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Affiliation(s)
- Zoltan G Turi
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, One Robert Wood Johnson Place, MEB 582A New Brunswick, NJ 08903, USA.
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Whisenant B, Weiss P. Left Atrial Appendage Closure with Transcatheter-Delivered Devices. Interv Cardiol Clin 2014; 3:209-218. [PMID: 28582166 DOI: 10.1016/j.iccl.2014.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Left atrial appendage (LAA) closure with transcatheter-delivered devices is an evolving story of compelling randomized data and the potential to dramatically reduce the incidence of stroke and improve the quality of life among patients with atrial fibrillation. Oral anticoagulation is the standard of care for stroke prevention in atrial fibrillation but falls short of providing an adequate solution to this common threat when considered from efficacy and safety perspectives. The robust series of Watchman device trials has demonstrated the Watchman device to provide stroke prevention efficacy similar to that of warfarin and by extension provides proof of concept of LAA closure.
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Affiliation(s)
- Brian Whisenant
- Division of Cardiology, Intermountain Medical Center, 5121 South Cottonwood Street, Level 6, Salt Lake City, UT 84157, USA.
| | - Peter Weiss
- Division of Cardiology, Intermountain Medical Center, 5121 South Cottonwood Street, Level 6, Salt Lake City, UT 84157, USA
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Onalan O, Lashevsky I, Hamad A, Crystal E. Nonpharmacologic stroke prevention in atrial fibrillation. Expert Rev Cardiovasc Ther 2014; 3:619-33. [PMID: 16076273 DOI: 10.1586/14779072.3.4.619] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Atrial fibrillation is associated with significant mortality and morbidity. The burden of morbidity in atrial fibrillation is mostly due to stroke, one of the major causes of death and the leading cause of long-term disability. Although highly effective in prevention of thromboembolic stroke, several factors limit utilization of chronic oral anticoagulation therapy. Eradication of atrial fibrillation and restoration of effective atrial contraction by surgical methods, or recently, by percutaneous catheter ablation methods, are two attractive approaches for stroke prophylaxis. Surgical exclusion of the left atrial appendage has generated considerable interest in the past decades and it is now performed routinely during mitral valve surgery in many centers. Recently, minimally invasive and percutaneous methods for the exclusion of left atrial appendage have been introduced. Currently, these approaches are being evaluated in ongoing trials. This review will discuss the current status of nonpharmacologic methods in the prevention of stroke in atrial fibrillation.
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Affiliation(s)
- Orhan Onalan
- Sunnybrook & Women's College Health Sciences Centre, Arrhythmia Services, Division of Cardiology, 2075 Bayview Avenue, B327, Toronto, Ontario, M4N 3M5, Canada.
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Horton RP, Doshi SK, Sánchez JE, Di Biase L, Natale A. Percutaneous Closure of the Left Atrial Appendage. Card Electrophysiol Clin 2012; 4:383-394. [PMID: 26939958 DOI: 10.1016/j.ccep.2012.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This article reviews the published evidence on stroke prevention with percutaneous closure of the left atrial appendage and provides comparative insight into the various left atrial appendage closure devices currently in development.
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Affiliation(s)
- Rodney P Horton
- Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, TX, USA; Department of Biomedical Engineering, University of Texas, Austin, TX, USA
| | - Shephal K Doshi
- Pacific Heart Institute/St Johns Hospital, Santa Monica, CA, USA
| | | | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, TX, USA; Department of Biomedical Engineering, University of Texas, Austin, TX, USA; Department of Cardiology, University of Foggia, Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, TX, USA
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Ailawadi G, Gerdisch MW, Harvey RL, Hooker RL, Damiano RJ, Salamon T, Mack MJ. Exclusion of the left atrial appendage with a novel device: early results of a multicenter trial. J Thorac Cardiovasc Surg 2011; 142:1002-9, 1009.e1. [PMID: 21906756 DOI: 10.1016/j.jtcvs.2011.07.052] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Revised: 07/04/2011] [Accepted: 07/25/2011] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Up to 90% of embolic strokes that occur in patients with atrial fibrillation originate from the left atrial appendage. Exclusion of the left atrial appendage during cardiac surgery may decrease the future risk of stroke, especially in patients with atrial fibrillation or at high risk for developing atrial fibrillation. We report the initial results of a multicenter Food and Drug Administration trial to assess the safety and efficacy of a novel left atrial appendage exclusion clip. METHODS Patients undergoing elective cardiac surgery via median sternotomy with atrial fibrillation or a Congestive Heart Failure, Hypertension, Age > 75 Years, Diabetes Mellitus, Stroke score greater than 2 were eligible for concomitant AtriClip (Atricure Inc, Westchester, Ohio) device insertion. Device insertion (35, 40, 45, and 50 mm) was performed at any point after sternotomy on or off cardiopulmonary bypass. Safety was assessed at 30 days, and efficacy of left atrial appendage exclusion was assessed at operation (by transesophageal echocardiography) and 3-month follow-up (by computed tomography angiography or transesophageal echocardiography). RESULTS A total of 71 patients (mean age, 73 years) undergoing open cardiac surgery at 7 US centers were enrolled in the study. The left atrial appendage in 1 patient was too small and did not meet eligibility criteria; the remaining 70 patients had successful placement of an AtriClip device. Intraprocedural successful left atrial appendage exclusion was confirmed in 67 of 70 patients (95.7%). Although significant adverse events occurred in 34 of 70 patients (48.6%), there were no adverse events related to the device and no perioperative mortality. At 3-month follow-up, 1 patient died and 65 of 70 patients (92.9%) were available for assessment. Of the patients who underwent imaging, 60 of 61 patients (98.4%) had successful left atrial appendage exclusion by computed tomography angiography or transesophageal echocardiography imaging. CONCLUSIONS In this small study, safe and atraumatic exclusion of the left atrial appendage can be performed during open cardiac surgery with the AtriClip device with greater than 95% success and appears to be durable in the short term by imaging. Long-term studies are needed to evaluate the efficacy in the prevention of stroke.
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Affiliation(s)
- Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Roth P, Rahimi A, Boening A. The Pericardium-Reinforced Technique of Amputation of the Left Atrial Appendage: Quick, Safe, and Simple. Ann Thorac Surg 2010; 90:e11-3. [DOI: 10.1016/j.athoracsur.2010.04.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 04/09/2010] [Accepted: 04/15/2010] [Indexed: 10/19/2022]
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Kanderian AS, Gillinov AM, Pettersson GB, Blackstone E, Klein AL. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol 2008; 52:924-9. [PMID: 18772063 DOI: 10.1016/j.jacc.2008.03.067] [Citation(s) in RCA: 392] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 02/26/2008] [Accepted: 03/11/2008] [Indexed: 12/15/2022]
Abstract
OBJECTIVES We sought to determine which surgical technique of left atrial appendage (LAA) closure is most successful by assessing them with transesophageal echocardiography (TEE). BACKGROUND Atrial fibrillation is a risk factor for stroke, with 90% of clots occurring in the LAA. Several surgical techniques of LAA closure are used to theoretically reduce the stroke risk, with varying success rates. METHODS A total of 137 of 2,546 patients who underwent surgical LAA closure from 1993 to 2004 had a TEE after surgery. Techniques consisted of either excision or exclusion by sutures or stapling. The TEE measurements included color Doppler flow in the LAA and interrogation for thrombus. Patent LAA, remnant LAA (residual stump >1 cm), or excluded LAA with persistent flow into the LAA were identified as unsuccessful closure. RESULTS Of the 137 patients, 52 (38%) underwent excision and 85 (62%) underwent exclusion (73 suture and 12 stapler). Only 55 of 137 (40%) of closures were successful. Successful LAA closure occurred more often with excision (73%) than suture exclusion (23%) and stapler exclusion (0%) (p < 0.001). We found LAA thrombus to be present in 28 of 68 patients (41%) with unsuccessful LAA exclusion versus none with excision. At time of TEE, 6 patients with successful LAA closure (11%) and 12 with unsuccessful closure (15%) had evidence of stroke/transient ischemic attack (p = 0.61). CONCLUSIONS There is a high occurrence of unsuccessful surgical LAA closure. Of the various techniques, excision appears to be the most successful.
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Affiliation(s)
- Anne S Kanderian
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Topkara VK, Williams MR, Cheema FH, Vigilance DW, Garrido MJ, Russo MJ, Oz MC, Argenziano M. Surgical ablation of atrial fibrillation: the Columbia Presbyterian experience. J Card Surg 2007; 21:441-8. [PMID: 16948752 DOI: 10.1111/j.1540-8191.2006.00273.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Maze III procedure is an effective surgical treatment for atrial fibrillation (AF). However, it is not widely applied due to its complexity, increased operative times, and the risk of bleeding. Various energy sources have been introduced to simplify the traditional "cut and sew" approach. METHODS This study involves patients undergoing surgical atrial fibrillation ablation (SAFA) at a single institution from 1999 to 2005. Type of concomitant procedures, preoperative clinical characteristics, and chronicity of AF were evaluated in overall patient population. Parameters including surgical approach, lesion pattern, and energy source used were collected intraoperatively. Clinical outcomes examined were postoperative rhythm success, stroke, early mortality, and long-term survival. RESULTS Three hundred thirty-nine patients were identified. Three hundred twenty-eight (96.8%) patients had associated cardiac disease and underwent concomitant procedures; 75.8% of patients had persistent AF. Energy sources used were microwave (49.8%), radiofrequency (42.2%), and laser (8.0%). In 41.9% of cases a pulmonary vein encircling lesion was the only lesion created. Combination lesion sets were performed in the remaining cases. Rhythm success rates at 3, 6, 12, and 24 months were 74.1%, 68.2%, 74.5%, and 71.1%, respectively. Patients who underwent surgical removal of left atrial appendage by means of stapling or simple excision had no early postoperative stroke. Early mortality was 4.9%. Postoperative survival rates at 1, 3, and 5 years were 89.6%, 83.1%, and 78.0%. CONCLUSIONS Surgical ablation of atrial fibrillation is a safe and effective procedure in restoring sinus rhythm with excellent postoperative survival rates. Further advancements in the field will eventually result in minimally invasive procedures with higher success rates.
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Affiliation(s)
- Veli K Topkara
- Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, Division of Cardiothoracic Surgery, New York, NY 10032, USA.
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Wong JWW, Mak KH. Impact of maze and concomitant mitral valve surgery on clinical outcomes. Ann Thorac Surg 2006; 82:1938-47. [PMID: 17062288 DOI: 10.1016/j.athoracsur.2006.05.108] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2004] [Revised: 05/16/2006] [Accepted: 05/18/2006] [Indexed: 10/24/2022]
Abstract
We evaluated the usefulness of the maze procedure among patients with atrial fibrillation undergoing mitral valve surgery. Seven matched-controlled and four randomized trials were identified from Medline English language papers (1995 to 2005). After 2 to 8 years of follow-up in matched-controlled studies, odds ratio and 95% confidence interval (CI) for atrial fibrillation free, embolic events free, and long-term survival for those treated with maze were 12.51 (95% CI: 9.18 to 17.03), 9.35 (95% CI: 5.11 to 17.13), and 2.27 (95% CI: 1.21 to 4.27), respectively. Correspondingly, after 1 to 1.5 years of follow-up in randomized trials, they were 9.01 (95% CI: 4.21 to 19.3), 5.19 (95% CI: 0.50 to 53.6), and 0.49 (95% CI: 0.12 to 1.93), respectively. The addition of the maze procedure to mitral valve surgery was more likely to maintain patients in sinus rhythm and may lower embolic events, including stroke, but did not necessarily improve long-term survival.
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Affiliation(s)
- James W W Wong
- Heart, Lung and Vascular Surgical Centre, Mount Elizabeth Medical Centre, Singapore.
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20
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Schneider B, Stollberger C, Sievers HH. Surgical Closure of the Left Atrial Appendage – A Beneficial Procedure? Cardiology 2005; 104:127-32. [PMID: 16118490 DOI: 10.1159/000087632] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Accepted: 12/27/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Closure of the fibrillating left atrial appendage (LAA) has been recommended during valve surgery to decrease the risk of arterial embolism. However, patients undergoing surgical LAA closure have not systematically been reevaluated for complete LAA obliteration. METHODS AND RESULTS During a 12-month period, we studied 6 consecutive patients with paroxysmal (n = 3) or permanent (n = 3) atrial fibrillation who underwent surgical LAA closure at the time of valve surgery. Transesophageal echocardiography (TEE) performed 23-159 days (mean 51) postoperatively demonstrated complete LAA closure in only 1 patient. In 5 patients, incomplete LAA closure was found due to disruption of the closure line. The size of the residual LAA orifice ranged from 3 to 20 mm. There was a high flow velocity at the LAA orifice (0.33-2.2 m/s), whereas flow in the LAA body was low (<0.2 m/s). Spontaneous echocardiographic contrast (SEC) in the LAA had newly developed (n = 3) or was much more intense than preoperatively (n = 2). Despite therapeutic anticoagulation 2 patients showed a LAA thrombus which had not been present on the preoperative TEE, and 1 patient with SEC suffered a stroke 4 weeks after attempted LAA closure. CONCLUSION Surgical LAA closure was incomplete in most patients, resulting in blood stagnation and an increased likelihood of clot formation. Incomplete surgical LAA closure, therefore, may promote rather than reduce the risk of stroke. Intraoperative TEE is mandatory to verify complete LAA obliteration.
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Affiliation(s)
- Birke Schneider
- Klinik fur Kardiologie, Sana Kliniken Lubeck GmbH, Deutschland.
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21
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Pennec PY, Jobic Y, Blanc JJ, Bezon E, Barra JA. Assessment of different procedures for surgical left atrial appendage exclusion. Ann Thorac Surg 2003; 76:2168-9. [PMID: 14667677 DOI: 10.1016/s0003-4975(03)00738-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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22
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Bakris N, Tighe DA, Rousou JA, Hiser WL, Flack JE, Engelman RM. Nonobstructive membranes of the left atrial appendage cavity: report of three cases. J Am Soc Echocardiogr 2002; 15:267-70. [PMID: 11875392 DOI: 10.1067/mje.2002.117630] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A membranous structure causing functional stenosis at the mouth of the left atrial appendage (LAA) has been reported. In this study we describe the presence of nonobstructive membranes traversing the cavity of the LAA found incidentally on transesophageal echocardiography (TEE).
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Affiliation(s)
- Nicholas Bakris
- Division of Cardiology, Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
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23
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Rosenzweig BP, Katz E, Kort S, Schloss M, Kronzon I. Thromboembolus from a ligated left atrial appendage. J Am Soc Echocardiogr 2001; 14:396-8. [PMID: 11337686 DOI: 10.1067/mje.2001.110328] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The left atrial appendage of patients with mitral valve disease is commonly a source of thromboembolus and is often ligated during mitral valve surgery to diminish this risk. However, ligation is often incomplete. We describe a patient with a stroke whose only source of embolus was an incompletely ligated left atrial appendage. Attempts to exclude the left atrial appendage from the arterial circulation by suture ligation may not decrease the risk of thromboemboli and instead may increase such risk.
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Affiliation(s)
- B P Rosenzweig
- Department of Medicine, New York University School of Medicine, New York, USA
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24
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Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol 2000; 36:468-71. [PMID: 10933359 DOI: 10.1016/s0735-1097(00)00765-8] [Citation(s) in RCA: 296] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study sought to determine the incidence of incomplete ligation of the left atrial appendage (LAA) during mitral valve surgery. BACKGROUND Ligation of the LAA to prevent future thromboembolic events is commonly performed during mitral surgery. However, success in completely excluding the appendage from the circulation has never been systematically assessed. METHODS Using transesophageal Doppler echocardiography, we studied 50 patients who underwent mitral valve surgery and ligation of the LAA. Thirty patients were studied immediately postoperative, and 20 patients were studied 6 days to 13 years after surgery. Incomplete ligation was detected by demonstrating a color jet traversing the separation between the left atrial body and appendage. RESULTS Transesophageal echocardiography detected incomplete LAA ligation in 18 of 50 (36%) patients. The incidence of incomplete ligation was not significantly different between patients studied immediately postoperative and patients studied at various times after surgery. Type of mitral surgery (repair vs. replacement), operative approach (sternotomy vs. port access), left atrial size or degree of mitral regurgitation did not significantly correlate with the incidence of incomplete appendage ligation. However, the power to detect a significant difference in left atrial size was only 64%. Spontaneous echo contrast or thrombus was identified within appendages in 9 of 18 (50%) patients with incomplete ligation, while 4 of these 18 (22%) patients had thromboembolic events. CONCLUSIONS Surgical LAA ligation is frequently incomplete. The similar incidence of incomplete ligation detected immediately postoperative and at various times thereafter suggest that this results from an intraoperative phenomenon rather than from gradual dehiscence of sutures over years. The incidence of incomplete left atrial ligation was unrelated to type of surgery, surgical approach, left atrial size or degree of mitral regurgitation. Residual communication between the incompletely ligated appendage and the left atrial body may produce a milieu of stagnant blood flow within the appendage and be a potential mechanism for embolic events.
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Affiliation(s)
- E S Katz
- Department of Medicine, New York University School of Medicine, New York, USA
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Abstract
Narrowing at the mouth of the left atrial appendage has been reported after partial surgical ligation of the appendage. This report describes a patient, without prior cardiac surgery, who had an anatomic narrowing at the opening of the left atrial appendage demonstrated by 2-dimensional, Doppler, and color Doppler echocardiography.
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Affiliation(s)
- B Coughlan
- Noninvasive Cardiac Imaging Laboratories, Department of Medicine, Section of Cardiology, The University of Chicago, IL 60637, USA
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26
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Abstract
The left atrial appendage is frequently ligated during mitral valve surgery to decrease the future risk of embolic events. The postoperative detection of a partially occluded left atrial appendage has previously been reported with the use of transesophageal echocardiography. We describe an unusual case in which Doppler echocardiography demonstrated a remarkably high-velocity jet emanating from a partially ligated left atrial appendage.
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Affiliation(s)
- D C Fisher
- Department of Medicine, New York University Medical Center, NY 10016, USA
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