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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study
E S Katz1, T Tsiamtsiouris, R M Applebaum
1Department of Medicine, New York University School of Medicine, New York, USA.
Insights
Surgical ligation of the left atrial appendage (LAA) is often incomplete, with 36% of patients showing residual communication. This suggests an intraoperative issue, not suture dehiscence, potentially increasing embolic event risk.
Area of Science:
- Cardiovascular Surgery
- Echocardiography
- Thromboembolic Event Prevention
Background:
- Left atrial appendage (LAA) ligation is a common strategy during mitral valve surgery to prevent thromboembolic events.
- The effectiveness of complete LAA exclusion from circulation has not been systematically evaluated.
Purpose of the Study:
- To determine the incidence of incomplete left atrial appendage (LAA) ligation following mitral valve surgery.
Main Methods:
- Transesophageal Doppler echocardiography was used to assess 50 patients post-mitral valve surgery with LAA ligation.
- Patients were studied either immediately postoperative or 6 days to 13 years after surgery.
- Incomplete ligation was identified by detecting a color jet across the LAA-left atrial body separation.
Main Results:
- Incomplete LAA ligation was detected in 36% (18/50) of patients.
- The incidence of incomplete ligation did not differ significantly between early and late postoperative assessments.
- No significant correlation was found between incomplete ligation and mitral surgery type, operative approach, left atrial size, or mitral regurgitation severity.
Conclusions:
- Surgical LAA ligation is frequently incomplete, likely due to intraoperative factors rather than suture dehiscence.
- Incomplete ligation may lead to stagnant blood flow within the LAA, increasing the risk of thromboembolic events.
- Further investigation into LAA management during mitral valve surgery is warranted.
Objectives:
This study sought to determine the incidence of incomplete ligation of the left atrial appendage (LAA) during mitral valve surgery.
Background:
Ligation of the LAA to prevent future thromboembolic events is commonly performed during mitral surgery. However, success in completely excluding the appendage from the circulation has never been systematically assessed.
Methods:
Using transesophageal Doppler echocardiography, we studied 50 patients who underwent mitral valve surgery and ligation of the LAA. Thirty patients were studied immediately postoperative, and 20 patients were studied 6 days to 13 years after surgery. Incomplete ligation was detected by demonstrating a color jet traversing the separation between the left atrial body and appendage.
Results:
Transesophageal echocardiography detected incomplete LAA ligation in 18 of 50 (36%) patients. The incidence of incomplete ligation was not significantly different between patients studied immediately postoperative and patients studied at various times after surgery. Type of mitral surgery (repair vs. replacement), operative approach (sternotomy vs. port access), left atrial size or degree of mitral regurgitation did not significantly correlate with the incidence of incomplete appendage ligation. However, the power to detect a significant difference in left atrial size was only 64%. Spontaneous echo contrast or thrombus was identified within appendages in 9 of 18 (50%) patients with incomplete ligation, while 4 of these 18 (22%) patients had thromboembolic events.
Conclusions:
Surgical LAA ligation is frequently incomplete. The similar incidence of incomplete ligation detected immediately postoperative and at various times thereafter suggest that this results from an intraoperative phenomenon rather than from gradual dehiscence of sutures over years. The incidence of incomplete left atrial ligation was unrelated to type of surgery, surgical approach, left atrial size or degree of mitral regurgitation. Residual communication between the incompletely ligated appendage and the left atrial body may produce a milieu of stagnant blood flow within the appendage and be a potential mechanism for embolic events.
