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Thoracoscopic obliteration of the left atrial appendage: potential for stroke reduction?
J A Odell1, J L Blackshear, E Davies
1Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
Insights
Thoracoscopic obliteration of the left atrial appendage is a feasible surgical technique for reducing stroke risk in atrial fibrillation patients. This method proved effective in animal models and human cadavers.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Procedures
- Thromboembolic Stroke Prevention
Background:
- Left atrial appendage thrombus is common in atrial fibrillation, particularly in rheumatic heart disease (43%) and nonrheumatic cases (91%).
- Thromboembolic stroke is a significant complication of atrial fibrillation.
Purpose of the Study:
- To assess the feasibility of thoracoscopic obliteration of the left atrial appendage.
- To evaluate this technique as a method for reducing thromboembolic stroke risk.
Main Methods:
- Thoracoscopic left atrial appendage obliteration was performed on 10 dogs using staples or an endoloop.
- The procedure was also attempted on 8 human cadavers.
Main Results:
- Successful and rapid appendage obliteration was achieved in all dogs, confirmed histologically after 11 weeks.
- In human cadavers, the procedure was successful in most cases, though anatomical factors or tearing complicated some attempts.
Conclusions:
- Left atrial appendage obliteration is a feasible surgical option to reduce stroke risk in atrial fibrillation.
- This procedure may be particularly beneficial for patients ineligible for warfarin or those without existing thrombus.
Background:
In a review of all relevant articles describing the site of left atrial thrombus in patients with atrial fibrillation, the thrombus was localized to the left atrial appendage in 43% of patients with rheumatic heart disease and in 91% of patients with nonrheumatic atrial fibrillation. This study was designed to test the feasibility of thoracoscopic obliteration of the left atrial appendage as a means of reducing thromboembolic stroke.
Methods:
Thoracoscopic obliteration of the left atrial appendage was undertaken in 10 dogs, 5 with staples and 5 with an endoloop. Obliteration also was attempted in 8 fresh human cadavers.
Results:
In all dogs, the appendage was rapidly obliterated (21.3 +/- 7.6 minutes) and confirmed at euthanasia at 11 weeks. In 3 cadavers, anatomic and disease factors prevented visualization of the left atrial appendage; in 1 the appendage tore, and in the remainder the appendage was obliterated.
Conclusions:
Obliteration of the left atrial appendage is feasible and may be considered as an additional surgical procedure to reduce stroke. The group of patients in whom it offers the greatest potential are those with atrial fibrillation deemed ineligible for warfarin, those without atrial thrombus and with a free pericardial and pleural space.