Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation

doi:10.1016/0003-4975(95)00887-X

The Annals of Thoracic Surgery

Volume 61, Issue 2, February 1996, Pages 755-759

https://doi.org/10.1016/0003-4975(95)00887-X Get rights and content

Background.

Left atrial appendage obliteration was historically ineffective for the prevention of postoperative stroke in patients with rheumatic atrial fibrillation who underwent operative mitral valvotomy. It is, however, a routine part of modern “curative” operations for nonrheumatic atrial fibrillation, such as the maze and corridor procedures.

Methods.

To assess the potential of left atrial appendage obliteration to prevent stroke in nonrheumatic atrial fibrillation patients, we reviewed previous reports that identified the etiology of atrial fibrillation and evaluated the presence and location of left atrial thrombus by transesophageal echocardiography, autopsy, or operation.

Results.

Twenty-three separate studies were reviewed, and 446 of 3,504 (13%) rheumatic atrial fibrillation patients, and 222 of 1,288 (17%) nonrheumatic atrial fibrillation patients had a documented left atrial thrombus. Anticoagulation status was variable and not controlled for. Thrombi were localized to, or were present in the left atrial appendage and extended into the left atrial cavity in 254 of 446 (57%) of patients with rheumatic atrial fibrillation. In contrast, 201 of 222 (91%) of nonrheumatic atrial fibrillation-related left atrial thrombi were isolated to, or originated in the left atrial appendage (p < 0.0001).

Conclusions.

These data suggest that left atrial appendage obliteration is a strategy of potential value for stroke prophylaxis in nonrheumatic atrial fibrillation.

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Cited by (1331)

Fluid-structure interaction analysis of the thromboembolic risk in the left atrial appendage under atrial fibrillation: Effect of hemodynamics and morphological features
2024, Computer Methods and Programs in Biomedicine
Complications of atrial fibrillation (AF) include ischemic events originating within the left atrial appendage (LAA), a protrusion of the left atrium with variable morphological characteristics. The role of the patient specific morphology and pathological haemodynamics on the risk of ischemia remains unclear.
This work performs a comparative assessment of the hemodynamic parameters among patient-specific LAA morphologies through fluid-structure interaction computational analyses. Three LAA models per each of the four commons patient-specific morphological families (chicken wing, cactus, windsock, and cauliflower) were analysed. Mechanical properties of the tissue were based on experimental uniaxial tests on a young pig's heart. Boundary conditions were imposed based on clinical assessments of filling and emptying volumes. Sinus rhythm and atrial fibrillation operative conditions were simulated and analysed.
For each model, the effect of morphological and functional parameters, such as the number of trabeculae and LAA stroke volume, over the hemodynamics established into the appendage was analysed. Comparison between results obtained in healthy and diseased conditions suggested the introduction of a new parameter to quantify the risk of thrombosis, here called blood stasis factor (BSF). This is defined as the LAA surface area which permanently experiences levels of shear strain rate inferior to a threshold value, set to 5 s⁻¹ (BSF5).
This work suggests that the current morphological classification is unsuitable to evaluate the probability of thrombus formation. However, hemodynamic parameters easy to determine from clinical examinations, such as normalised stroke volume, LAA orifice flow rate and presence of extensive trabeculations can identify departures from healthy hemodynamics in AF and support a more systematic stratification of the thromboembolic risk.
Comparing safety and efficacy: MemoLefort versus watchman for left atrial appendage closure
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The MemoLefort is a new plug occluder for left atrial appendage closure (LAAC) in patients with atrial fibrillation (AF). This study compares the safety and efficacy of MemoLefort and the well-established Watchman occluder for LAAC.
Between January 2021 and September 2022, a cohort of 189 consecutive patients who underwent LAAC with MemoLefort or Watchman at The Second Affiliated Hospital of Wenzhou Medical University were included. Patients with MemoLefort or Watchman devices were compared in terms of the primary safety endpoints encompassing major periprocedural complications and major bleeding events at follow-up, the primary efficacy endpoint of all-cause stroke, systemic embolism and cardiovascular/unexplained death, and the combined hazard endpoint, a composite of all the above-mentioned hazards.
Of the MemoLefort group (n = 83) and Watchman group (n = 106), the mean age, CHA₂DS₂-VASc score, and HAS-BLED score were 67.6 ± 9.2 vs. 69.0 ± 10.6 years, 3.9 ± 1.9 vs. 3.8 ± 1.9, and 1.6 ± 1.0 vs. 1.7 ± 1.2, respectively. After a median follow-up duration of 198 (99–329) vs. 334 (171–497) days, the primary endpoints of efficacy [2/49, 4.1% (MemoLefort) vs. 2/97, 2.1% (Watchman); hazard ratio (HR), 1.50; 95% confidence interval (CI), 0.20–11.08; P = 0.68] and safety (1/49, 2.0% vs. 5/97, 5.2%; HR, 0.26; 95% CI, 0.05–1.31; P = 0.19), as well as the combined hazard endpoint (3/49, 61% vs. 6/97, 6.2%; HR, 0.70; 95% CI, 0.18–2.58; P = 0.59) were similar between groups.
In the short term, LAAC with MemoLefort provided similar efficacy, safety, and net clinical benefit in comparison to Watchman devices.
2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2024, Journal of the American College of Cardiology
The “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation” provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.
A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.
Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the “2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” and the “2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Left Atrial Appendage Closure: Therapy Overview and Future Perspective
2024, Cardiology Clinics
Association of transcatheter left atrial appendage occlusion with acute changes in left atrial pressure: An invasive hemodynamic study
2024, Heart Rhythm
The hemodynamic effects of transcatheter left atrial appendage occlusion (LAAO) remain unclear.
We sought to assess the effect of LAAO on invasive hemodynamics and their correlation with clinical outcomes.
We recorded mean left atrial pressure (mLAP) before and after device deployment. We assessed the prevalence and predictors of mLAP increase after deployment, the association between significant mLAP increase after deployment and 45-day peridevice leak (PDL), and the association between mLAP increase and heart failure (HF) hospitalization. A significant mLAP increase was defined as one equal to or greater than the mean percentage increase in mLAP after deployment (≥28%).
We included 302 patients (36.4% female; mean age, 75.8 ± 9.5 years). After deployment, mLAP increased in 48% of patients, 38% of whom experienced significant mLAP increase. Independent predictors of mLAP increase were baseline mLAP ≤14 mm Hg, nonparoxysmal atrial fibrillation, and age per 5 years (odds ratios: 3.66 [95% CI, 2.21–6.05], 1.81 [95% CI, 1.08–3.02], and 0.85 [95% CI, 0.73–0.99], respectively). Significant mLAP increase was an independent predictor of 45-day PDL (odds ratio, 2.55; 95% CI, 1.04–6.26). There was no association between mLAP increase and HF hospitalization.
After deployment, mLAP acutely rises in 48% of patients, although this is not associated with increased HF hospitalizations. PDL is more likely to develop at 45 days in patients with significant increase in mLAP after deployment, although most leaks were small (<5 mm). These findings suggest that mLAP increase after deployment is not associated with major safety concerns. Additional studies are warranted to explore the long-term hemodynamic effects of LAAO.
Left atrial appendage closure in patients with left atrial appendage thrombus guided by intracardiac echocardiography
2024, Heart Rhythm
Data regarding left atrial appendage closure (LAAC) in patients with left atrial appendage (LAA) thrombus are limited. Recently published cases have mostly been guided by transesophageal echocardiography. Intracardiac echocardiography (ICE) is now widely used during LAAC procedures.
This is the first study to report the feasibility of LAAC in patients with LAA thrombus guided by ICE.
Patients with persistent LAA thrombus despite anticoagulation or contraindications to anticoagulation who underwent a modified ICE-guided LAAC procedure between June 2021 and April 2023 were included. Periprocedural events and clinical outcomes during follow-up were recorded.
A total of 12 patients (mean age 65 ± 7 years; 92% male) were included: 10 with persistent LAA thrombus and 2 with contraindications to anticoagulation. Most of the thrombus was at the apex (n = 6), followed by the body (n = 3) and the ostium (n = 3). A LAmbre device was used and successfully implanted in all patients with the guidance of ICE. No thrombotic material was retrieved from patients with the protection of cerebral protection device (n = 11). No patient experienced severe periprocedural complications. All patients completed transesophageal echocardiography follow-up, and no device-related thrombus or peridevice leak > 3 mm was detected. None of the patients experienced stroke/transient ischemic attack, systemic embolism, or major bleeding events during a median follow-up of 147 days (interquartile range 80–306 days).
LAAC using the LAmbre device guided by ICE may be feasible in patients with LAA thrombus when performed by experienced operators.

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Current reviewAppendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation

Background.

Methods.

Results.

Conclusions.

Resection of the left auricular appendix

JAMA

Commissurotomy for mitral stenosis: technique for prevention of cerebral complications

JAMA

Systemic embolism and left auricular thrombosis in relation to mitral valvotomy

Br Med J

Mural thrombosis and arterial embolism in mitral stenosis

Circulation

Open mitral commissurotomy

A modern reevaluation

J Thorac Cardiovasc Surg

Open mitral valvotomy: effect of preoperative factors on result

J Thorac Cardiovasc Surg

The surgical treatment of atrial fibrillation: IV. Surgical technique

J Thorac Cardiovasc Surg

Surgical treatment of atrial fibrillation

J Thorac Cardiovasc Surg

Restoration of atrial function after the maze procedure for patients with atrial fibrillation: assessment by Doppler echocardiography

Circulation

Surgical treatment of atrial fibrillation

Herz

Five-year experience with the maze procedure for atrial fibrillation

Ann Thorac Surg

Cox maze procedure for chronic atrial fibrillation associated with mitral valve disease

J Thorac Cardiovasc Surg

Atrial fibrillation as an independent risk factor for stroke: the Framingham study

Stroke

Risk factors for stroke and efficacy of anti-thrombotic therapy in atrial fibrillation: analysis of pooled data from five randomized controlled trials

Arch Intern Med

Silent cerebral infarction in chronic atrial fibrillation

Stroke

Predictors of thromboembolism in atrial fibrillation: II. Echocardiographic features of patients at risk

Ann Intern Med

Atrial size, atrial fibrillation and stroke

Ann Neurol

Mitral regurgitation associated with reduced thromboembolic events in high-risk patients with nonrheumatic atrial fibrillation

Am J Cardiol

Atrial fibrillation and stroke: three new studies, three remaining questions

Arch Intern Med

Trial of different intensities of anticoagulation in patients with prosthetic heart valves

N Engl J Med

Thromboembolic risk and late survival after mitral valve replacement with the St. Jude medical valve

Ann Thorac Surg

Anticoagulation in atrial fibrillation: does efficacy in clinical trials translate into effectiveness in practice?

Arch Intern Med

A clinical report on the use of Quinidin sulphate

Arch Int Med

Sensitivity and specificity of transesophageal echo for left atrial thrombi: a prospective, consecutive surgical study

Circulation

Transesophageal echo (TEE) facilitated early cardioversion for patients with new atrial fibrillation: a 4-year experience

Circulation

Prognostic implications of left atrial spontaneous echo contrast in nonvalvular atrial fibrillation

J Am Coll Cardiol

Clinical features of intracardiac thrombosis based on echocardiographic observation

Jpn Circ J

Role of transesophageal echocardiography in detecting left atrial thrombus and spontaneous echo contrast in patients with mitral valve disease or non-rheumatic atrial fibrillation

J Formosan Med Assoc

Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus

J Am Coll Cardiol

Current review
Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation