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Ann Thorac Surg 2003;76:2168-2169
© 2003 The Society of Thoracic Surgeons

Correspondence

Assessment of different procedures for surgical left atrial appendage exclusion

Pierre-Yves Pennec, MDa, Yannick Jobic, MDa, Jean-Jacques Blanc, MDa, Eric Bezon, MDb, Jean-Aubert Barra, MDb

a Department of Cardiology Hôpital de la Cavale Blanche, Boulevard Tanguy Prigent 29609 Brest Cedex, France
b Department of Cardiovascular Surgery, Hôpital de la Cavale, Blanche, France

e-mail: jean-jacques.blanc{at}univ-brest.fr

To the Editor:

Stroke is the most fearsome complication of atrial fibrillation (AF). In a current review published in 1996, Blackshear and Odell [1] reported that the source of 91% of nonrheumatic AF–related left atrial thrombi was the left atrial appendage (LAA), and the authors subsequently concluded that LAA obliteration could be a strategy potentially valuable for stroke prevention in nonrheumatic AF. After examining this study, we decided to obliterate the LAA in the course of routine cardiac surgical procedures when patients had permanent or transient AF (in the absence of LAA thrombus). In the first series of 20 patients with documented paroxysmal or persistent nonrheumatic AF who were operated on preponderantly for degenerative valvular disease or coronary heart disease, we obliterated the mouth of the LAA by an intraatrial running suture. Paradoxically, 2 well-anticoagulated patients, while in sinus rhythm, had a stroke within the first 2 weeks after operation. One died rapidly. In the other patient, transesophageal echocardiography revealed a thrombus inside the LAA and an incompletely obliterated LAA communicating with the left atrium. Transesophageal echocardiography was performed in the 4 subsequent patients. In 1 of them, LAA exclusion was incomplete with thrombus inside the LAA (this patient had no embolic events). In this short retrospective study, there appeared to be a strong relationship between incomplete obliteration of the LAA and the incidence of stroke.

Thus, in a second series of 10 patients, we chose to obliterate the LAA using separate mattress stitches. One patient sustained a stroke postoperatively. Transesophageal echocardiography revealed a thrombus in the LAA as well as incomplete LAA obliteration. Therefore, we decided to abandon endocardial suture of the LAA.

Currently, obliteration of the LAA is included in some interventions such as the maze procedure [2], and in our opinion, it is also very important for the prevention of stroke. We designed a prospective series with systematic postoperative transesophageal echocardiography control. Thirty patients (27 having mitral valve repair and 3, mitral valve replacement, all with preoperative history of AF) underwent LAA exclusion using an external technique: clamping and ligating the base of the LAA. The ligation was secured by one transfixing mattress suture. The LAA was then excised to check the effectiveness of the obliteration and the absence of leaks. No strokes were observed during a mean follow-up of 110 days, and postoperative transesophageal echocardiography showed complete exclusion of the LAA in all patients.

Some case reports [3, 4] and one study [5] have suggested the possibility of incomplete exclusion of the LAA after endocardial suturing. In our experience, intraatrial obliteration of the LAA is dangerous, whereas external obliteration is safe. Is obliteration of the LAA relevant for stroke prevention in patients with AF? A large series with long follow-up is needed to confirm this hypothesis. The aim of this letter is to advise surgical teams who would perform such studies to use safe external method and avoid intraatrial LAA obliteration.

References

  1. Blackshear J.L., Odell J.A. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996;61:755-759.[Abstract/Free Full Text]
  2. Cox J.L. The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg 1991;101:584-592.[Abstract]
  3. Lynch M., Shanewise J.S., Chang G.L., Martin R.P., Clements S.D. Recanalization of the left atrial appendage demonstrated by transesophageal echocardiography. Ann Thorac Surg 1997;63:1774-1775.[Abstract/Free Full Text]
  4. Fisher D.C., Tunick P.A., Kronzon I. Large gradient across a partially ligated left atrial appendage. J Am Soc Echocardiogr 1998;11:1163-1165.[Medline]
  5. Katz E.S., Tsiamtsiouris T., Applebaum R.M., Schwartzbard A., Tunick P.A., Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiographic study. J Am Coll Cardiol 2000;36:468-471.[Abstract/Free Full Text]



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