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Updated: May 26, 2025
Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
Published on: February 8, 2022
The efficiency of endocardial suture occlusion of the left atrial appendage at a single institution: MICs vs.
Chengfeng Huang1, Jiawen Huang2, Si Shen3
1Department of Cardiovascular Surgery, The First Affiliated Hospital, Jinan University, 613 Whampoa Avenue, Tianhe District, Guangzhou, 510630, China.
Insights
Minimally invasive cardiac surgery (MICS) for left atrial appendage closure (LAAC) showed a higher rate of residual shunting compared to sternotomy. Reinforcing suture margins during MICS may improve closure success rates.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Thrombosis Prevention
Background:
- Left atrial appendage (LAA) thrombi are a primary source of thromboembolic stroke.
- LAA closure is a recognized strategy for stroke prevention.
- Surgical LAA closure can be performed via endocardial or epicardial techniques, including during minimally invasive cardiac surgery (MICS) and sternotomy.
Purpose of the Study:
- To evaluate the efficacy and outcomes of left atrial appendage closure (LAAC) performed using MICS.
- To compare the success rates of LAAC between MICS and sternotomy approaches.
Main Methods:
- Retrospective analysis of 74 patients undergoing LAAC during valve operations (2017-2021).
- LAA closure achieved via endocardial continuous suture.
- Comparison between 42 MICS patients and 32 sternotomy patients; post-operative CT, echocardiography, and ECG for assessment.
Main Results:
- Successful LAAC was achieved in 81% of sternotomy patients versus 48% of MICS patients.
- Residual shunting was significantly more frequent in the MICS group (p=0.003).
- No correlation found between residual shunting and left atrial/ventricular dimensions or function; leak incidence independent of mitral valve procedure type.
Conclusions:
- MICS for LAAC demonstrated a higher incidence of residual shunting compared to sternotomy.
- CT analysis revealed residual shunting predominantly at suture margins in MICS failures.
- Suture margin reinforcement is proposed to potentially decrease incomplete closure rates in MICS.
Background:
Most thrombi originate from the left atrial appendage (LAA), preventing thromboembolic stroke is an important aspect of stroke prevention. Previous studies have found that LAA closure is beneficial for preventing thrombosis. Currently, surgical procedures can achieve LAA closure by closing the endocardium or epicardium. LAA endocardial suture technique is performed concomitantly during sternotomy cardiac surgery but can also be performed during right minimally invasive cardiac surgery (MICS).
Aims:
This study aims to evaluate the efficacy of left atrial appendage closure (LAAC) with MICS.
Methods:
A total number of 74 patients who underwent LAAC during valve operation between 2017 and 2021 were retrospectively analyzed in this study. LAA was closed by continuous suture through the endocardium of the left atrium during cardiac surgery. 42 patients performed LAA endocardial suture during MICS, while 32 patients performed with the same LAAC technique during sternotomy. Patients underwent cardiac computed tomography (CT) follow-up after surgery to verify the completeness of the LAAC. The heart structure and function were recorded by echocardiography Transthoracic echocardiography (TTE), and the heart rhythm was recorded by electrocardiogram.
Results:
The LAA closure procedure was successful in 26 cases (81%) in the sternotomy group and 20 cases (48%) in the right minimally invasive group. Residual shunting (failed LAA closure) was more common in the right minimally invasive group (p = 0.003), and no correlation was found between residual shunting and left atrial (LA), left ventricular end-diastolic diameter (LVDD), and left ventricular ejection fraction (LVEF). The incidence of leaks was not associated with mitral valve replacement or valvuloplasty.
Conclusions:
Compared to sternotomy, residual shunting after MICS was more common. CT imaging analysis of 22 patients with failed closure in the MICS group showed that residual shunting was mainly concentrated on margins of the suture (anterior superior and posterior inferior) (86%), with a middle area accounting for 3 (14%). Based on this finding, reinforcing the suture margins may significantly reduce the incidence of incomplete closure.
The Clinical Trial Number:
KY-2023-001.
