Surgical Strategies and Devices for Surgical Exclusion of the Left Atrial Appendage: A Word of Caution

Apostolakis, Efstratios; Papakonstantinou, Nikolaos; Baikoussis, Nikolaos G; Koniari, Ioanna; Papadopoulos, George

doi:10.1111/jocs.12055

Cited by 12 publications

(6 citation statements)

References 56 publications

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“…Closure of the LAA is a well-established approach during arrhythmia surgery or with concomitant cardiac surgery [ 15 , 16 ]. Surgical LAA removal or closure performed during concomitant arrhythmia or mitral valve surgery was demonstrated to be feasible and safe by the LAAOS trial [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Is there an alternative treatment for patients intolerant to antiplatelet therapy if percutaneous left atrial appendage closure is considered?

et al. 2017

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IntroductionLeft atrial appendage (LAA) closure has become of major interest for patients with atrial fibrillation intolerant to oral anticoagulation therapy (OAC). Patients with a contraindication to both OAC and antiplatelet therapy are not eligible for percutaneous LAA closure. We aimed to find an alternative treatment for these specific patients.MethodsFrom March 2014 until December 2015 five patients were referred for percutaneous LAA closure. Alternative treatment was necessary due to an absolute contraindication to OAC and antiplatelet therapy (n = 4) or after previous failed percutaneous device implantation (n = 1). A stand-alone full thoracoscopic closure of the LAA using the Atriclip PRO device (AtriCure Inc., Dayton, OH, USA) was performed under guidance of transoesophageal echocardiography (TEE). After three months all patients underwent a computed tomography scan. Mean follow-up was 7.2 months [range 4.5–9.8 months].ResultsAll procedures were achieved without the occurrence of complications. Complete LAA closure was obtained in all patients without any residual flow confirmed by TEE. Postoperative computed tomography confirmed persisting adequate clip positioning with complete LAA closure and absence of intracardial thrombi. During follow-up no thromboembolic events occurred.ConclusionFor atrial fibrillation patients with an absolute contraindication to OAC and antiplatelet therapy a stand-alone, minimally invasive thoracoscopic closure of the LAA is a safe and feasible alternative treatment. This might be a solution to avoid serious bleeding complications while eliminating the thromboembolic risk originating from the LAA in patients who are not eligible for percutaneous LAA closure.

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Section: Discussionmentioning

confidence: 99%

Is there an alternative treatment for patients intolerant to antiplatelet therapy if percutaneous left atrial appendage closure is considered?

et al. 2017

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Section: Discussionmentioning

confidence: 99%

“…Surgical LAA closure has been performed to prevent thromboembolic events during valve surgery and coronary artery bypass grafting or, more recently, as an isolated procedure using a thoracoscopic approach, 3,4) because most of the atrial thrombi are seen within the LAA. 3) Schwartz and colleagues 5) experimentally and clinically studied mechanisms of healing and intracardiac integration in LAA exclusion by a mechanical device and demonstrated that the excluded LAA filled with a thrombus early after exclusion, and that the thrombus subsequently organized over time.…”

Section: Discussionmentioning

confidence: 99%

“…4) Generally, the successfully excluded LAA is filled with a thrombus and the thrombus eventually organizes late after exclusion. 5) In this paper, we report progressive enlargement of a successfully excluded LAA that was filled with a thrombus in a patient who had undergone valve surgery and endocardial suture closure of the LAA previously, and discuss a pathophysiologic mechanism of enlargement of an LAA with a thrombus.…”

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confidence: 99%

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Enlargement of the Excluded Left Atrial Appendage With Thrombus

2017

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SummaryWe report progressive enlargement of the excluded left atrial appendage (LAA) with a thrombus in a patient who had undergone valve surgery and endocardial suture closure of the LAA previously. Echocardiography and CT detected no communication between the LAA and the left atrium. Magnetic resonance imaging showed the LAA was filled with fresh and old thrombi. Coronary arteriography demonstrated small left coronary artery-LAA fistulae. At surgery, successful exclusion of the LAA was confirmed after removal of the thrombi. Persistent inflow of blood through the coronary artery fistulae to the excluded LAA may be the primary mechanism of this pathology. (Int Heart J 2017; 58: 144-146) Key words: Atrial fibrillation, Embolism, Exclusion of the left atrial appendage, Left atrium I n patients with atrial fibrillation (AF), exclusion of the left atrial appendage (LAA) is recommended to prevent thromboembolic events, [1][2][3] and it can be accomplished with various techniques such as suture ligation or stapling devices. 4) Generally, the successfully excluded LAA is filled with a thrombus and the thrombus eventually organizes late after exclusion. 5)In this paper, we report progressive enlargement of a successfully excluded LAA that was filled with a thrombus in a patient who had undergone valve surgery and endocardial suture closure of the LAA previously, and discuss a pathophysiologic mechanism of enlargement of an LAA with a thrombus.The current study was approved by our Institutional Research Ethics Board at St. Mary's Hospital, and patient consent was waived. Case ReportA 79-year-old woman with persistent AF was admitted for an abnormality on cardiac silhouette. The patient had a history of valve surgery for rheumatic valve disease and endocardial suture exclusion of the LAA 13 years before. On admission, she was asymptomatic and on anticoagulant therapy with warfarin. Chest X-rays showed moderate cardiomegaly with progressive local protrusion of the left border of the cardiac silhouette. Transthoracic echocardiography (TTE) revealed a dilated left atrium (LA) and normally functioning aortic and mitral prosthetic valves. A solid mass, 45 × 51 mm in size, which was just adjacent to the body of the LA and was clearly demarcated from the enlarged LA, was also delineated on both TTE and chest CT, but contrast enhancement of the mass was not observed on CT ( Figure 1A, 1B). Magnetic resonance imaging demonstrated that the mass contained fresh and old thrombi ( Figure 1C, 1D). Coronary arteriography revealed normal arteries, however, small fistulae from the left coronary artery to the LAA were observed (Figure 2). Based on these findings, enlargement of the successfully excluded LAA filled with a thrombus was suspected. Surgical removal of the LAA was planned because of its expanding nature. Intraoperative transesophageal echocardiography (TEE) showed no communication between the LA and the LAA. After dissection of the pericardium through a median sternotomy, the solidified and enlarged LAA was found and was ...

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“…In this context, a degree of thrombotic risk reduction has been achieved with techniques that modify the LAA anatomy to decrease thrombus formation ability. These techniques began with surgical methods to amputate the LAA or suture the LAA os closed [9,10], and thereby eliminate clots and the release of thrombi from the LAA into the central systemic circulation. These surgical approaches, although imperfect, have achieved some success, as discussed below.…”

Section: Thromboembolicmentioning

confidence: 99%

Percutaneous Left Atrial Appendage Occlusion Therapy: Past, Present, and Future

Han

Dong

Benditt

2023

CVIA

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Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is increasing in incidence and prevalence worldwide. AF significantly increases the risk of intracardiac thrombus formation and, if left untreated, ischemic stroke. In patients with nonvalvular AF (NVAF), the left atrial appendage (LAA) has been determined to be the source of thrombus development in 91% to 99% of cases. In this regard, oral anticoagulants (OACs) have become the standard treatment for stroke prevention in most patients with AF; however, OACs are associated with a risk of bleeding complications, and their efficacy depends on optimal patient compliance. Among alternative approaches to embolic stroke prevention, surgical LAA excision for stroke prevention for valvular AF was attempted as early as the late 1940s. LAA excision remains recommended in surgical guidelines for patients with NVAF requiring open-heart coronary bypass or valvular replacement/repair surgeries. However, owing to the traumatic/invasive nature and suboptimal outcomes of conventional surgical LAA intervention, clinical application of this approach is limited in current cardiology practice. Percutaneous LAA occlusion (LAAO) is increasingly being performed as an alternative to OAC for stroke prevention, particularly in patients with elevated bleeding risk. Substantial progress has been made in percutaneous LAAO therapy since its inception approximately 20 years ago. This article systematically reviews the literature leading to the development of LAAO and the evidence-based clinical experience supporting the application of this treatment strategy for NVAF, with a focus on recently published critical evaluations of US FDA and CE mark approved LAAO devices. Future perspectives regarding knowledge and technology gaps are also discussed, recognizing the many ongoing clinical trials that are likely to be transformative and the critical unanswered questions regarding LAAO therapy.

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Surgical Strategies and Devices for Surgical Exclusion of the Left Atrial Appendage: A Word of Caution

Cited by 12 publications

References 56 publications

Is there an alternative treatment for patients intolerant to antiplatelet therapy if percutaneous left atrial appendage closure is considered?

Is there an alternative treatment for patients intolerant to antiplatelet therapy if percutaneous left atrial appendage closure is considered?

Enlargement of the Excluded Left Atrial Appendage With Thrombus

Percutaneous Left Atrial Appendage Occlusion Therapy: Past, Present, and Future

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