TY - JOUR
T1 - A randomized, prospective pilot comparison of 3 atrial appendage elimination techniques
T2 - Internal ligation, stapled excision, and surgical excision
AU - Lee, Richard
AU - Vassallo, Patricia
AU - Kruse, Jane
AU - Malaisrie, S. Chris
AU - Rigolin, Vera
AU - Andrei, Adin Cristian
AU - McCarthy, Patrick
N1 - Publisher Copyright:
© 2016 The American Association for Thoracic Surgery
PY - 2016/10/1
Y1 - 2016/10/1
N2 - Background Elimination of the left atrial appendage (LAA) attempts to reduce stroke in patients with atrial fibrillation (AF). A retrospective review suggests that various surgical techniques are often unsuccessful and may leave a stump or gap. In a pilot study, we prospectively evaluated 3 surgical techniques with long-term follow up to define effectiveness. Methods At a single institution, 28 patients undergoing concomitant AF surgery were randomized prospectively into 1 of 3 techniques of LAA elimination: internal suture ligation (IL), external stapled excision (StEx), and surgical excision (SxEx). The success of LAA elimination was assessed by transesophageal echocardiography (TEE) in all patients at the time of surgery. Failure of LAA closure consisted of either a stump (residual appendage tissue >1 cm in maximum length) or a gap (persistent flow between the left atrium [LA] and the LAA). Failure was treated intraoperatively when recognized. Late follow-up was obtained using a TEE at a mean of 0.4 years in 21/28 (75%) of patients. Results Early failure was recognized and treated in 1 patient in the IL group (13%), 6 patients in the StEx group (60%), and 2 patients in the SxEx group (20%) (P = .06). On follow-up TEE, 4 of 7 patients in the IL group (57%) had developed gaps, 3 of whom (43%) with greater than mild flow. No patients in the StEx or SxEx groups had a gap (P = .03). In late follow-up, 1 of 7 patients in the IL group (14%) had a stump, compared with 2 of 8 (25%) in the StEx group and 3 of 6 (50%) in the SxEx group (P = .35). The overall failure rate was 57%: 5 of 8 (63%) in the IL group, 6 of 10 (60%) in the StEx group, and 5 of 10 (50%) in the SxEx group (P = .85). No patient had a stroke at any time during follow-up. Conclusions LAA elimination is often incomplete and goes undetected. If the LAA is eliminated at the time of surgery, then TEE should be used intraoperatively to assess effectiveness and reintervention performed if warranted. Late assessment for completeness of closure should be considered before cessation of anticoagulation until more effective LAA techniques can be developed.
AB - Background Elimination of the left atrial appendage (LAA) attempts to reduce stroke in patients with atrial fibrillation (AF). A retrospective review suggests that various surgical techniques are often unsuccessful and may leave a stump or gap. In a pilot study, we prospectively evaluated 3 surgical techniques with long-term follow up to define effectiveness. Methods At a single institution, 28 patients undergoing concomitant AF surgery were randomized prospectively into 1 of 3 techniques of LAA elimination: internal suture ligation (IL), external stapled excision (StEx), and surgical excision (SxEx). The success of LAA elimination was assessed by transesophageal echocardiography (TEE) in all patients at the time of surgery. Failure of LAA closure consisted of either a stump (residual appendage tissue >1 cm in maximum length) or a gap (persistent flow between the left atrium [LA] and the LAA). Failure was treated intraoperatively when recognized. Late follow-up was obtained using a TEE at a mean of 0.4 years in 21/28 (75%) of patients. Results Early failure was recognized and treated in 1 patient in the IL group (13%), 6 patients in the StEx group (60%), and 2 patients in the SxEx group (20%) (P = .06). On follow-up TEE, 4 of 7 patients in the IL group (57%) had developed gaps, 3 of whom (43%) with greater than mild flow. No patients in the StEx or SxEx groups had a gap (P = .03). In late follow-up, 1 of 7 patients in the IL group (14%) had a stump, compared with 2 of 8 (25%) in the StEx group and 3 of 6 (50%) in the SxEx group (P = .35). The overall failure rate was 57%: 5 of 8 (63%) in the IL group, 6 of 10 (60%) in the StEx group, and 5 of 10 (50%) in the SxEx group (P = .85). No patient had a stroke at any time during follow-up. Conclusions LAA elimination is often incomplete and goes undetected. If the LAA is eliminated at the time of surgery, then TEE should be used intraoperatively to assess effectiveness and reintervention performed if warranted. Late assessment for completeness of closure should be considered before cessation of anticoagulation until more effective LAA techniques can be developed.
KW - atrial fibrillation
KW - left atrial appendage
KW - maze
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U2 - 10.1016/j.jtcvs.2016.06.009
DO - 10.1016/j.jtcvs.2016.06.009
M3 - Article
C2 - 27422360
AN - SCOPUS:84991072029
SN - 0022-5223
VL - 152
SP - 1075
EP - 1080
JO - Journal of Thoracic and Cardiovascular Surgery
JF - Journal of Thoracic and Cardiovascular Surgery
IS - 4
ER -