Thoracoscopic obliteration of the left atrial appendage: Potential for stroke reduction?

doi:10.1016/0003-4975(95)00885-3

The Annals of Thoracic Surgery

Volume 61, Issue 2, February 1996, Pages 565-569

https://doi.org/10.1016/0003-4975(95)00885-3 Get rights and content

Background.

In a review of all relevant articles describing the site of left atrial thrombus in patients with atrial fibrillation, the thrombus was localized to the left atrial appendage in 43% of patients with rheumatic heart disease and in 91% of patients with nonrheumatic atrial fibrillation. This study was designed to test the feasibility of thoracoscopic obliteration of the left atrial appendage as a means of reducing thromboembolic stroke.

Methods.

Thoracoscopic obliteration of the left atrial appendage was undertaken in 10 dogs, 5 with staples and 5 with an endoloop. Obliteration also was attempted in 8 fresh human cadavers.

Results.

In all dogs, the appendage was rapidly obliterated (21.3 ± 7.6 minutes) and confirmed at euthanasia at 11 weeks. In 3 cadavers, anatomic and disease factors prevented visualization of the left atrial appendage; in 1 the appendage tore, and in the remainder the appendage was obliterated.

Conclusions.

Obliteration of the left atrial appendage is feasible and may be considered as an additional surgical procedure to reduce stroke. The group of patients in whom it offers the greatest potential are those with atrial fibrillation deemed ineligible for warfarin, those without atrial thrombus and with a free pericardial and pleural space.

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Imaging reveals a fifth heart chamber: Diagnosing and treating a massive left atrial appendage aneurysm
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In this case report, a 33-year-old male with a history of smoking presented with recurrent palpitations and chest discomfort. Holter monitoring revealed atrial flutter, and imaging showed a giant left atrial appendage aneurysm. Due to the risk of arrhythmias and thromboembolic events, surgical resection was performed successfully. This case underscores the importance of considering uncommon structural cardiac abnormalities in the evaluation of arrhythmia symptoms in young patients.
Reduced Left Atrial Appendage Flow Is Associated With Future Atrial Fibrillation After Cryptogenic Stroke
2023, Journal of the American Society of Echocardiography
Hemostasis within the left atrial appendage (LAA) is a common cause of stroke, especially in patients with atrial fibrillation (AF). Although LAA flow provides insights into LAA function, its potential for predicting AF has yet to be established. The aim of this study was to explore whether LAA peak flow velocities early after cryptogenic stroke are associated with future AF on prolonged rhythm monitoring.
A total of 110 patients with cryptogenic stroke were consecutively enrolled and underwent LAA pulsed-wave Doppler flow assessment using transesophageal echocardiography within the early poststroke period. Velocity measurements were analyzed offline by an investigator blinded to the results. Prolonged rhythm monitoring was conducted on all participants via 7-day Holter and implantable cardiac monitoring devices, with follow-up conducted over a period of 1.5 years to determine the incidence of AF. The end point of AF was defined as irregular supraventricular rhythm with variable RR interval and no detectable P waves lasting ≥30 sec during rhythm monitoring.
During a median follow-up period of 539 days (interquartile range, 169-857 days), 42 patients (38%) developed AF, with a median time to AF diagnosis of 94 days (interquartile range, 51-487 days). Both LAA filling velocity and LAA emptying velocity (LAAev) were lower in patients with AF (44.3 ± 14.2 and 50.7 ± 13.3 cm/s, respectively) compared with patients without AF (59.8 ± 14.0 and 76.8 ± 17.3 cm/sec, respectively; P < .001 for both). LAAev was most strongly associated with future AF, with an area under the receiver operating characteristic curve of 0.88 and an optimal cutoff value of 55 cm/sec. Age and mitral regurgitation were independent determinants of reduced LAAev.
Impaired LAA peak flow velocities (LAAev < 55 cm/sec) in patients with cryptogenic stroke are associated with future AF. This may facilitate the selection of appropriate candidates for prolonged rhythm monitoring to improve its diagnostic accuracy and implementation.
Left Atrial Appendage Occlusion for The Unmet Clinical Needs of Stroke Prevention in Nonvalvular Atrial Fibrillation
2019, Mayo Clinic Proceedings
Oral anticoagulation is the dominant strategy for stroke prevention in patients with nonvalvular atrial fibrillation. However, lifelong oral anticoagulation is associated with major issues including inappropriate dosing, nonadherence, and adverse effects. Therefore, efforts have been made to develop site-specific therapy aimed to occlude the left atrial appendage, the anatomical site accountable for more than 90% of nonvalvular atrial fibrillation–related ischemic strokes. This review focuses on the growing literature to put into perspective the risk-balance ratio of left atrial appendage occlusion.
Left Atrial Appendage Electrical Isolation as a Target in Atrial Fibrillation
2019, JACC: Clinical Electrophysiology
Citation Excerpt :
A key concern specifically pertaining to LAAEI by ablation is the concern for increased thromboembolic risk. In nonvalvular AF, LAA is implicated as the source of thrombus in approximately 90% of AF patients who form thrombus, highlighting the baseline thrombotic potential of the structure (25,26). Electric isolation of the appendage may lead to electromechanical dissociation, which can further promote thrombus formation and increase stroke risk.
Although the benefit of catheter ablation of the pulmonary veins is well established in paroxysmal atrial fibrillation (AF), the optimal ablation strategy for persistent AF is yet to be determined. Pulmonary vein isolation in persistent AF often results in AF recurrence and the success rate may be low even after multiple procedures. Recurrent AF risk may be secondary to non–pulmonary vein triggers, and adjunctive therapies to better control persistent AF are under investigation. The left atrial appendage (LAA) is a complex structure with distinct physiological and electrical properties, and multiple studies have implicated the LAA as a potential contributor to persistence of AF. Therapies targeting the LAA for electrical isolation have demonstrated potential efficacy in freedom from AF. The overarching concept of this therapy is to isolate the atria electrically from the LAA via catheter ablation, surgical excision or ligation, or percutaneous ligation. LAA electrical isolation has already demonstrated benefit in reducing AF recurrence and AF burden. LAA electrical isolation has the potential to form a foundational piece in the optimal rhythm control management of AF and therefore warrants further study and is the focus of this review.
Devices for percutaneous appendage occlusion in the prevention of embolism in atrial fibrillation
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Left Atrial Appendage Ligation in Nonvalvular Atrial Fibrillation Patients at High Risk for Embolic Events with Ineligibility for Oral Anticoagulation Initial Report of Clinical Outcomes
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Citation Excerpt :
One patient had an unsuccessful closure with a partially closed posterior lobe; an embolic event occurred in this patient. The observation of an embolic event occurring in the patient with incomplete closure of the entire LAA is consistent with surgical literature of an increased risk of cardioembolic events noted with partial closures of the LAA (33–35); this highlights the need to ascertain complete capture of all LAA lobes before releasing the suture from the snare. Thrombus formation following LAA ligation was seen in 2 patients (1.4%) at the site of LAA closure, but thrombus formation did not lead to any cardioembolic events.
This study sought to assess long-term clinical outcomes in adults with nonvalvular atrial fibrillation (AF) who are ineligible for oral anticoagulation therapy and underwent left atrial appendage (LAA) ligation with the Lariat device.
LAA exclusion has been used to prevent thrombus formation within the LAA in AF patients and is believed to decrease the risk of cardioembolic events.
LAA ligation with the Lariat device was performed in 139 patients with nonvalvular AF. LAA closure was verified during the procedure by LA angiography and transesophageal echocardiography. A follow-up transesophageal echocardiography was performed at 30 to 45 days post-procedure. After the procedure, patients received aspirin only, clopidogrel only, aspirin plus clopidogrel, or no antithrombotic drugs. Patients did not receive transition oral anticoagulation therapy post-LAA ligation. Patients were followed for LAA closure and adverse events, including stroke, systemic events, and death.
Acute closure was accomplished in 138 of 139 treated patients (99%). In 1 patient, a posterior lobe was partially closed. At the day-30 to day-45 transesophageal echocardiography (n = 127), 114 (90%) had complete LAA closure, and 13 (10%) had a 2- to 4-mm leak. There were no leaks ≥5 mm. The periprocedural adverse event rate was 11.5%, including 2 cardiac perforations and 1 death due to pulmonary embolus. Over a mean follow-up of 2.9 ± 1.1 years, the event rate for the composite endpoint of stroke and systemic embolism was 1.0% per year (n = 4). The combined stroke, embolism, and death of any cause event rate was 2.8% (n = 11) per year.
The findings from this analysis of post-procedure event rates suggest that LAA ligation with the Lariat device effectively closes the LAA and may be a beneficial approach to reduce the risk of embolic events in AF patients ineligible to oral anticoagulation therapy. However, future randomized clinical trials are needed to verify these results and to determine device and procedural safety.

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: The study was supported by a grant from the Mayo Foundation (A22994) and in part from a grant by Ethicon Endosurgery.

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Original article: CardiovascularThoracoscopic obliteration of the left atrial appendage: Potential for stroke reduction?

Background.

Methods.

Results.

Conclusions.

Ann Thorac Surg

Lancet

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Original article: Cardiovascular
Thoracoscopic obliteration of the left atrial appendage: Potential for stroke reduction?