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CLINICAL RESEARCH: CARDIAC SURGERY

Success of Surgical Left Atrial Appendage Closure

Assessment by Transesophageal Echocardiography

Anne S. Kanderian, MD^_*, A. Marc Gillinov, MD, Gosta B. Pettersson, MD, PhD, Eugene Blackstone, MD and Allan L. Klein, MD, FACC^_*,_*

^_* Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio

Manuscript received November 27, 2007; revised manuscript received February 26, 2008, accepted March 11, 2008.

^_* Reprint requests and correspondence: Dr. Allan L. Klein, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk F15, Cleveland, Ohio 44195 (Email: kleina{at}ccf.org).

Objectives: We sought to determine which surgical technique of left atrial appendage (LAA) closure is most successful by assessing them with transesophageal echocardiography (TEE).

Background: Atrial fibrillation is a risk factor for stroke, with 90% of clots occurring in the LAA. Several surgical techniques of LAA closure are used to theoretically reduce the stroke risk, with varying success rates.

Methods: A total of 137 of 2,546 patients who underwent surgical LAA closure from 1993 to 2004 had a TEE after surgery. Techniques consisted of either excision or exclusion by sutures or stapling. The TEE measurements included color Doppler flow in the LAA and interrogation for thrombus. Patent LAA, remnant LAA (residual stump >1 cm), or excluded LAA with persistent flow into the LAA were identified as unsuccessful closure.

Results: Of the 137 patients, 52 (38%) underwent excision and 85 (62%) underwent exclusion (73 suture and 12 stapler). Only 55 of 137 (40%) of closures were successful. Successful LAA closure occurred more often with excision (73%) than suture exclusion (23%) and stapler exclusion (0%) (p < 0.001). We found LAA thrombus to be present in 28 of 68 patients (41%) with unsuccessful LAA exclusion versus none with excision. At time of TEE, 6 patients with successful LAA closure (11%) and 12 with unsuccessful closure (15%) had evidence of stroke/transient ischemic attack (p = 0.61).

Conclusions: There is a high occurrence of unsuccessful surgical LAA closure. Of the various techniques, excision appears to be the most successful.

Key Words: atrial fibrillation • left atrial appendage • surgical left atrial appendage closure • left atrial appendage thrombus • stroke

Abbreviations and Acronyms   AF = atrial fibrillation   ANP = atrial natriuretic peptide   LAA = left atrial appendage   TEE = transesophageal echocardiography   TIA = transient ischemic attack

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