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The left atrial appendage: our most lethal human attachment! Surgical implications
W D Johnson1, A K Ganjoo, C D Stone
1Department of Cardiovascular Surgery, St. Francis Hospital, 3300 South 16th Street, Milwaukee, WI 53215, USA. life@johnsonheartcare.com
Insights
Surgical removal of the left atrial appendage can prevent deadly emboli in atrial fibrillation patients. This procedure is safe during open-heart surgery and technically feasible via a minimally invasive approach for those with chronic atrial fibrillation.
Area of Science:
- Cardiology
- Surgical Innovation
- Embolic Stroke Prevention
Background:
- Atrial fibrillation significantly increases stroke risk, with over 90% of embolic strokes originating from the left atrial appendage.
- The left atrial appendage is a primary source of emboli responsible for atrial fibrillation-related deaths.
Purpose of the Study:
- To evaluate the surgical feasibility and safety of left atrial appendage removal (appendectomy) in preventing embolic strokes.
- To assess prophylactic appendectomy during open-heart surgery and therapeutic appendectomy in chronic atrial fibrillation patients.
Main Methods:
- Experimental thorascopic appendectomy in goats demonstrated successful closure with stapling.
- Safety of human appendectomy was assessed in 437 patients undergoing open-heart surgery (1995-1997).
- Technical feasibility of thorascopic appendectomy was demonstrated in seven patients with chronic atrial fibrillation.
Main Results:
- Prophylactic appendectomy during open-heart surgery showed no acute bleeding or identified late complications.
- Thorascopic appendectomy was successfully performed in seven patients with chronic atrial fibrillation.
- Stapling or suture closure resulted in cleaner, non-puckered atrial closure compared to purse-string techniques.
Conclusions:
- Left atrial appendage removal is a viable strategy to prevent emboli in atrial fibrillation patients.
- Prophylactic appendectomy during open-heart surgery is recommended to mitigate future stroke risk.
- Minimally invasive thorascopic appendectomy is a feasible approach for chronic atrial fibrillation patients, with further studies planned to confirm stroke prevention efficacy.
Objectives:
To prevent death from atrial fibrillation, a cardiac disease which kills by producing emboli. Atrial fibrillation causes about 25% of strokes and increases stroke rate by five times. Over 90% of these embolic strokes are from clots originating in the left atrial appendage. This study addresses the surgical feasibility of removing the appendage to prevent future deaths in two subcategories of patients. (1) Prophylactic removal during open-heart surgery to study its safety. Theoretically, as these patients age and some develop atrial fibrillation, protection from embolic strokes would already be present. (2) Therapeutic removal in chronic atrial fibrillation patients by means of a thorascopic approach. Its technical feasibility is demonstrated. Its actual stroke prevention potential awaits large studies.
Methods:
Appendectomy has been evaluated three ways. (1) Experimentally, thorascopic appendage removal was performed on 20 goats with endoscopic approach. Late studies showed a cleanly healed atrial closure after stapling, and no puckering of tissue as seen with the purse-string approach. (2) Safety of human appendectomy was demonstrated in 437 patients (1995-1997). Routine appendectomy was performed during open-heart surgery. Forty-three appendages were stapled, 391 sutured off. (3) Thorascopic appendectomy in seven patients with chronic atrial fibrillation has been successfully accomplished as an isolated surgical procedure. Stapling or suture closure provides a much cleaner, non-puckered suture line than a purse string.
Results:
In prophylactic removal, no acute bleeding occurred. No late problems have been identified. Endoscopic removal of the appendage has been successful in seven atrial fibrillation patients.
Conclusions:
The left atrial appendage is a lethal source of emboli in atrial fibrillation patients. As patients age and often develop atrial fibrillation, prophylactic appendage removal whenever the chest is open is suggested as a method to prevent future strokes. In chronic atrial fibrillation patients, appendectomy can be done with a mini-thorascopic approach. Further studies are planned to demonstrate the effectiveness of appendectomy in preventing strokes in the chronic fibrillating patients.