Elsevier

The Annals of Thoracic Surgery

Volume 92, Issue 6, December 2011, Pages 2283-2292
The Annals of Thoracic Surgery

Review
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter Experiences

https://doi.org/10.1016/j.athoracsur.2011.08.044Get rights and content

Since the 1950s, the pathophysiologic role of the left atrial appendage (LAA) has been known in thromboembolic disease. A variety of surgical techniques have been described to close the LAA, with various degrees of efficacy. Today, transcatheter devices for LAA occlusion may offer a less invasive solution. This review looks at the surgical experience with LAA occlusion, with a focus on the techniques of closure, the prospects for stroke reduction, and the percutaneous trials completed so far, to formulate some meaningful conclusions about the status of LAA closure today.

Section snippets

Material and Methods

An English language literature search was performed using OVID, Medline, and the Cochrane Library for all studies from 1948 to April 2011. The medical subject heading terms and keywords included combinations of “left atrial appendage,” “surgery for left atrial appendage,” “left auricular appendage,” “stroke prevention,” and “percutaneous closure left atrial appendage.” The “related articles” feature and additional references in identified articles were used to expand the search.

LAA Anatomy and Physiology

The 2-cm to 4-cm-long tubular LAA usually forms a narrow junction with the LA and angles downward from its origin; in contrast, the right atrial appendage is more broad-based and triangular, forming a wide junction to the right atrium at an upward angle that makes stasis less likely [10]. Clinical studies using TEE [11] and magnetic resonance angiography [12] demonstrate significant heterogeneity among AF patients in LAA size, wall thickness, and morphology. The LAA is located on the lateral

History of LAA Exclusion and Removal

Belcher and Somerville [21] noted the relationship between rheumatic MV disease, systemic embolism, and the LAA in observing that LAA thrombus was present in 64% of these patients who presented with TE events compared with 16% in those who did not. LAA obliteration was first suggested as an adjunct to mitral valvotomy before the advent of cardiopulmonary bypass. Madden (1949) [22] published one of the first reports of LAA removal in 2 patients. Interestingly, he reviewed three reports from the

Surgical Techniques for LAA Occlusion

Johnson and colleagues [25] described the LAA as “our most lethal human attachment” in a report of prophylactic LAA excision in 437 patients from 1995 to 1997. In this group, there were 21 perioperative cerebrovascular accidents, but there were no later strokes or demonstrable thrombus seen by TEE. Consequently, the authors recommended an aggressive strategy of LAA excision in patients undergoing heart operations. There have been a number of techniques for management of the LAA. Broadly, they

Results With Various Surgical Techniques

The surgical literature on LAA closure consists primarily of retrospective case series of patients who had LAA occlusion and then later presented with new findings warranting TEE evaluation. As such, there is a selection bias because only a small segment of the treated population is studied. Nevertheless, it is possible to gather some meaningful insights. It is important in each of these prior reports to focus on the technique used for surgical obliteration of the LAA.

One randomized trial

Summary of Surgical Techniques

The echocardiography literature has numerous additional examples of failure of endocardial suture closure [34] and epicardial closure [35]. A closer examination of the efficacy of the various closure techniques is reported in Table 1. It is apparent that endocardial ligation alone appears to be an inferior method of closure compared with stapling. The main limitation to stapling is the large (>1 cm) remnant that is left behind, although two studies [28, 29] found no thrombus on TEE even if

Newer Surgical Techniques

Pericardial reinforced techniques [43] or an inversion and excision method [44] are other alternative excision techniques. Each method might offer satisfactory results, although an advantage over the simple oversew is unlikely. In an effort to offer a less invasive LAA occlusion, Blackshear and colleagues [45] described successful thoracoscopic obliteration of the LAA using a stapled or snare technique. The procedure was completed in 14 of 15 patients, with one conversion to thoracotomy for

Transcatheter Closure Devices

During the last decade, several transcatheter devices have been developed for the management of the LAA in AF patients. Three devices have been investigated: the Percutaneous LAA Transcatheter Occlusion or PLAATO System (eV3, Plymouth, MN), the Amplatzer Cardiac Plug (St. Jude Medical, Minneapolis, MN), and the Watchman (Boston Scientific, Maple Grove, MN) device. All are delivered percutaneously through transseptal access to the LA [49]. Preprocedural evaluation of the LA and LAA, exclusion of

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