Incomplete surgical ligation of the left atrial appendage—time for a new look at an old problem

Aryana, Arash; Bhaskar, Rohit

doi:10.21037/atm.2017.02.17

Cited by 11 publications

(10 citation statements)

References 26 publications

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“…In a retrospective study by Kanderian et al ., surgical ligation of the LAA was successful in only 55 of 137 patients (40%), indicating the high prevalence of incomplete surgical ligation ( 2 ). Reports of incomplete LAA closure have ranged from 10 to 80%; however, in two studies specifically investigating surgical LAA ligation in association with mitral valve surgery, as in our patient’s case, the reported incidences of incomplete surgical closure of the LAA were 35 and 36% ( 1 , 3 , 4 ). The presence of a mitral valvular annuloplasty ring or prosthesis has been associated with increased risk of incomplete surgical closure of the LAA due to failure to extend sutures to the most distal edge of the LAA to avoid these structures ( 3 ).…”

Section: Discussionmentioning

confidence: 51%

The clot thickens: an incompletely ligated left atrial appendage

Thomas¹,

Grodzinsky²,

Zink³

2018

Echo Res Pract

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SummaryOur patient presented with known mechanical mitral valve endocarditis documented by 2D transesophageal echocardiogram (TOE) from a recent hospitalization at an outside facility. On admission to our center, there was no prior knowledge of an incompletely ligated left atrial appendage (LAA) according to patient- or family-reported history, review of outside records or the outside facility’s 2D TOE report. A 3D TOE performed at our center to assess her pathology, since a month had passed from her prior hospitalization, revealed a LAA ligation with evidence of communication to the left atrium and with clot present in the appendage. This case report highlights the common finding of incomplete closure of the LAA following surgical ligation, thus making it inadequate for stroke prevention in patients with atrial fibrillation, and that 3D TOE plays a valuable role in assessing the durability of LAA ligation.Learning points:3D transesophageal echocardiography (TOE) is a valuable tool in assessing the durability of left atrial appendage (LAA) ligation given the superior image granularity as compared with 2D TOE.LAA ligation may not be adequate for stroke prevention in patients with atrial fibrillation as incomplete closure is common following surgical ligation.LAA occlusion should be considered in these cases.

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Section: Discussionmentioning

confidence: 51%

The clot thickens: an incompletely ligated left atrial appendage

Thomas¹,

Grodzinsky²,

Zink³

2018

Echo Res Pract

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“…6,15,16,35 Therefore, although it is theoretically possible for thrombi to form in the residual pouch because of persistent flow of blood and increased stagnation within the "stenotic" LAA, thrombi seem to develop infrequently in the stump cavity especially in the smooth vestibule of the residual pouch in the off-OAC patients. 36 One of our patients experienced a stroke during the late follow-up period. Of note, this patient had amyloid vasculitis for which she received the clip and was kept off OAC.…”

Section: Discussionmentioning

confidence: 89%

“…in all patients in sinus rhythm if their follow-up TEE ruled out any LA thrombus.At the follow-up TEE at 6 and 12 months, no thrombus was detected in the LAA stump in any of our patients. Therefore, although it is theoretically possible for thrombi to form in the residual pouch because of persistent flow of blood and increased stagnation within the "stenotic" LAA, thrombi seem to develop infrequently in the stump cavity especially in the smooth vestibule of the residual pouch in the off-OAC patients 36. Therefore, although it is theoretically possible for thrombi to form in the residual pouch because of persistent flow of blood and increased stagnation within the "stenotic" LAA, thrombi seem to develop infrequently in the stump cavity especially in the smooth vestibule of the residual pouch in the off-OAC patients 36.…”

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confidence: 99%

Arrhythmogenecity and thrombogenicity of the residual left atrial appendage stump following surgical exclusion of the appendage in patients with atrial fibrillation

Mohanty

Biase

Trivedi

et al. 2019

Cardiovasc electrophysiol

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Introduction It is common to find residual stump after the amputation or clip exclusion of the left atrial appendage (LAA). We evaluated the arrhythmogenic and thrombogenic potential of LAA stumps in atrial fibrillation (AF) patients. Methods Consecutive patients undergoing catheter ablation for AF recurrence with LAA stump detected at baseline transesophageal echocardiogram (TEE) were included in the analysis. Nonpulmonary vein (non‐PV) triggers were ablated based on operator's discretion. Results A total of 213 patients with LAA stump were included in the analysis. Firing from the LAA stump was detected in 186 cases, of which 145 received stump isolation (group I) and the stump was not targeted for isolation in 41 (group II) patients. In 27 patients with no firing from the stump (group III) only non‐PV triggers from sites other than the LAA stump were targeted for ablation. At 16.7 ± 8.5 months of follow‐up, 126 (86.9%) patients from group I, eight (19.5%) from group II, and eight (33.3%) from group III remained arrhythmia‐free off antiarrhythmic drugs (AAD) (P < 0.001). Sixty out of 70 patients underwent redo procedure; electrical isolation of the stump and ablation of other non‐PV triggers was done in all 60 cases. At 1 year after the repeat procedure, 55 (91.7%) patients remained arrhythmia‐free off‐AAD. A total of four (1.88%) thromboembolic (TE) events reported, three of which were transient ischemic attacks and all three patients had “smoke” detected in the left atrium. Conclusion LAA stump is arrhythmogenic and electrical isolation improves clinical outcome. TE events are rare and mostly associated with left atrial smoke in this subset of AF population.

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“…4). В одном из 29 случаев при полной перевязке выявлена остаточная культя длиной 8 мм, что, по мнению ряда авторов [3,4], является близким к критерию неполной перевязки ушка ЛП.…”

Section: результатыunclassified

“…Из всех методик это единственный способ выполнения резекции ушка, однако использование данного устройства приводит к образованию остаточной культи после операции. Такая ситуация наблюдается более чем в половине случаев [3,4,8]. В нашем исследовании мы оценили эффективность и безопасность турникетного лигирования ушка левого предсердия на этапе его торакоскопической абляции.…”

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Turnstile left atrial appendage occlusion during thoracoscopic ablation

Шиленко¹,

Tsoy²,

Черкес³

et al. 2017

Kardiol. serdechno-sosud. khir.

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Фибрилляция предсердий (ФП) является наиболее распространенным типом нарушения ритма, который выявляется примерно у 1-2% взрослого населения. Наряду с развитием и прогрессированием сердечной недостаточности, при ФП значительно повышается риск тромбоэмболических осложнений. Риск ишемического инсульта и системной эмболизации у этих пациентов возрастает в 5 раз [1]. Общеизвестно, что более чем в 90% случаев местом формирования тромбов является ушко левого предсердия (ЛП), вследствие его анатомического строения и особенностей гемодинамики [2]. По этой причине хирурги уделяют изоляции ушка левого предсердия особое внимание, особенно у пациентов с фибрилляцией предсердий. Однако лигирование ушка может часто приводить к

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Incomplete surgical ligation of the left atrial appendage—time for a new look at an old problem

Cited by 11 publications

References 26 publications

The clot thickens: an incompletely ligated left atrial appendage

The clot thickens: an incompletely ligated left atrial appendage

Arrhythmogenecity and thrombogenicity of the residual left atrial appendage stump following surgical exclusion of the appendage in patients with atrial fibrillation

Turnstile left atrial appendage occlusion during thoracoscopic ablation

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