Related Experiment Video
Updated: Sep 9, 2025
Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
Published on: February 8, 2022
Postoperative Transesophageal Echocardiographic Evaluation of Surgical Left Atrial Appendage Exclusion:
Karl M Richardson1,2, Karanpreet K Dhaliwal3, Sebastian S Hernandez2
1Section on Cardiology, Atrium Health Wake Forest Baptist Medical Center, Winston Salem, North Carolina, USA.
Insights
Surgical left atrial appendage (LAA) exclusion for atrial fibrillation stroke risk reduction had an 82% success rate. Postoperative TEE revealed LAA remnants in many patients, indicating a need for further research on remnant relevance.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Imaging
Background:
- Surgical left atrial appendage (LAA) exclusion is a strategy to reduce stroke risk in patients with atrial fibrillation.
- Incomplete LAA exclusion and the presence of LAA remnants are potential concerns.
- Limited transesophageal echocardiogram (TEE) data exist on the evaluation of LAA remnants after surgical exclusion.
Purpose of the Study:
- To evaluate the success of LAA exclusion using TEE in patients who underwent surgical excision (SE), AtriClip occlusion (AO), or Tiger Paw occlusion (TO).
- To assess LAA remnant characteristics, including depth, flow, and presence of thrombus or suture, across different exclusion techniques.
Main Methods:
- Analysis of postoperative TEE images from 121 patients who underwent LAA exclusion.
- Assessment of LAA remnant depth, flow into remnant, and visible suture, thrombus, or pectinate.
- Definition of successful LAA exclusion as a remnant depth <1 cm at all imaging angles.
Main Results:
- Overall successful LAA exclusion was achieved in 82% of patients (99/121).
- Success rates varied numerically by technique: SE (86%), AO (76%), TO (57%), without statistical significance.
- LAA remnants were observed, with flow into remnants in 4.4% (SE), 15.0% (AO), and 20.0% (TO). Thrombus was noted in 2 SE cases.
Conclusions:
- Postoperative TEE revealed a significant rate of LAA remnants after surgical exclusion, suggesting potential for incomplete exclusion by current standards.
- Further investigation is required to determine the clinical significance of these LAA remnants and their characteristics.
Background:
Mounting evidence suggests surgical left atrial appendage (LAA) exclusion reduces stroke risk in patients with atrial fibrillation. Prior older research suggests that LAA exclusion is often incomplete, but few transesophageal echocardiogram (TEE) data exist evaluating LAA remnants.
Methods:
We analyzed 121 patients with an available postoperative TEE who underwent LAA exclusion by surgical excision (SE), AtriClip occlusion (AO), or Tiger Paw occlusion (TO). TEE images were assessed for LAA remnant depths, presence of flow into remnant, and visible suture, thrombus, or pectinate. Successful LAA exclusion was defined as a remnant with depth past LAA ostium <1 cm in all available imaging angles.
Results:
Left atrial appendage exclusion was successful in 99/121 (82%) patients. Success varied numerically but not statistically by technique; 73/85 (86%), 22/29 (76%), 4/7 (57%) in the SE, AO, and TO groups, respectively. SE group had similar mean and max (cm) remnant depths (0.56 ± 0.32 and 0.65 ± 0.38) compared to the AO group (0.68 ± 0.38 and 0.81 ± 0.49) and TO group (0.69 ± 0.30 and 0.83 ± 0.40). Flow into LAA remnant was seen in 4.4% (SE), 15.0% (AO), and 20.0% (TO). Residual pectinate was seen in 18.8% (SE), 13.8% (AO), and 14.3% (TO); 8% in SE group had visible suture. Thrombus was seen in 2 cases within the SE group. In multivariable models, diabetes and heart failure predicted max LAA depth.
Conclusions:
Postoperative TEE examination of LAA remnants revealed a relatively high failure rate by current standards. More data are needed to evaluate the clinical relevance of LAA remnant characteristics.
