ReviewLeft Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter Experiences
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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2021, Journal of Cardiothoracic and Vascular AnesthesiaRole of the Left Atrial Appendage in Systemic Homeostasis, Arrhythmogenesis, and Beyond
2020, Cardiac Electrophysiology ClinicsCitation Excerpt :For many decades, the LAA has been implicated in the formation of thrombus and thromboembolic events. In the 1950s, Belcher and Somerville19,20 noted that LAA thrombus was present in greater than 60% of patients with a history of rheumatic valve disease undergoing mitral valvotomy who presented with thromboembolic events. LAA excision was first done during mitral valvotomy for this reason.
Appendacide? Really?
2020, Journal of Thoracic and Cardiovascular SurgeryLeft Atrial Appendage Occlusion: A Narrative Review
2019, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :This contrasts with other reports suggesting that only 57% of thrombi originated in the LAA in patients with valvular atrial fibrillation, the remainder arising from elsewhere in the left atrium.4,28,30 This finding had key implications for patient selection in LAAO, suggesting more benefit in patients with nonvalvular atrial fibrillation.9,21,28,30,31 Anticoagulants, such as warfarin, are used widely and are effective in reducing thromboembolic events in patient with atrial fibrillation.
History of Percutaneous Left Atrial Appendage Occlusion with AMPLATZER Devices
2018, Interventional Cardiology Clinics