Effect of the surgical strategies of left atrial appendage on stroke prevention in patients with atrial fibrillation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

XU Qiyue ^1,2 , SUN Yiren ² , OUMAR Abdel Mahamoud ² , CAI Jie ² ,  QIAN Yongjun ²

1. School of Basic Medicine, Mudanjiang Medical University, Mudanjiang, 157011, Heilongjiang, P. R. China;
2. Department of Cardiovascular Surgery, West China Hospital, Med-X Center for Materials, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding author：

QIAN Yongjun, Email: qianyongjun@scu.edu.cn

Keywords：

Atrial fibrillation; left atrial appendage; stroke; auricle clamp

DOI：

10.7507/1007-4848.202407054

Video：

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[Abstract ]Atrial fibrillation is one of the most common arrhythmias and significantly increases the risk of stroke, and the left atrial appendage is the main source of thrombus. Therefore, the management of the left atrial appendage in the surgical treatment of atrial fibrillation can effectively prevent stroke. However, there are various strategies to manage the left atrial appendage, each with advantages and disadvantages, and their effect of stroke prevention are not the same. Therefore, we evaluated the three most common surgical strategies, including left atrial appendage resection, left atrial appendage ligation and left atrial appendage clamp. We discussed the effect of these strategies on stroke prevention based on multiple dimensions such as surgical difficulty, surgical cost and postoperative stroke incidence, thus trying to provide some guidance for the selection of left atrial appendage treatment in patients with atrial fibrillation.

1.	Kimura T, Takatsuki S, Miyoshi S, et al. Pericardial endoscopy-guided left atrial appendage ligation: A pilot study in a canine model. Circ Cardiovasc Interv, 2014, 7(6): 844-850.
2.	Murtaza G, Boda U, Turagam MK, et al. Risks and benefits of removal of the left atrial appendage. Curr Cardiol Rep, 2020, 22(11): 129.
3.	January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 2014, 64(21): e1-76.
4.	Kanderian AS, Gillinov AM, Pettersson GB, et al. Success of surgical left atrial appendage closure: Assessment by transesophageal echocardiography. J Am Coll Cardiol, 2008, 52(11): 924-929.
5.	Ramlawi B, Abu Saleh WK, Edgerton J. The left atrial appendage: Target for stroke reduction in atrial fibrillation. Methodist Debakey Cardiovasc J, 2015, 11(2): 100-103.
6.	Wolf PA, Dawber TR, Thomas HE, et al. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: The Framingham study. Neurology, 1978, 28(10): 973-977.
7.	Krahn AD, Manfreda J, Tate RB, et al. The natural history of atrial fibrillation: Incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med, 1995, 98(5): 476-484.
8.	Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke, 1991, 22(8): 983-988.
9.	Price MJ, Valderrábano M. Left atrial appendage closure to prevent stroke in patients with atrial fibrillation. Circulation, 2014, 130(2): 202-212.
10.	Ahmed A, Pothineni NVK, Singh V, et al. Long-term imaging and clinical outcomes of surgical left atrial appendage occlusion with AtriClip. Am J Cardiol, 2023, 201: 193-199.
11.	Kreidieh B, Rojas F, Schurmann P, et al. Left atrial appendage remodeling after lariat left atrial appendage ligation. Circ Arrhythm Electrophysiol, 2015, 8(6): 1351-1358.
12.	Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg, 1996, 61(2): 755-759.
13.	Johnson WD, Ganjoo AK, Stone CD, et al. The left atrial appendage: Our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg, 2000, 17(6): 718-722.
14.	Lakkireddy D, Sridhar Mahankali A, Kanmanthareddy A, et al. Left atrial appendage ligation and ablation for persistent atrial fibrillation: The LAALA-AF registry. JACC Clin Electrophysiol, 2015, 1(3): 153-160.
15.	Yamada T, McElderry HT, Allison JS, et al. Focal atrial tachycardia originating from the epicardial left atrial appendage. Heart Rhythm, 2008, 5(5): 766-767.
16.	Di Biase L, Burkhardt JD, Mohanty P, et al. Left atrial appendage: An underrecognized trigger site of atrial fibrillation. Circulation, 2010, 122(2): 109-118.
17.	Güner A, Kalçık M, Gündüz S, et al. The relationship between incomplete surgical obliteration of the left atrial appendage and thromboembolic events after mitral valve surgery (from the ISOLATE Registry). J Thromb Thrombolysis, 2021, 51(4): 1078-1089.
18.	Auer J, Lamm G. Left atrial appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med, 2021, 385(11): 1053.
19.	Blackshear JL, Johnson WD, Odell JA, et al. Thoracoscopic extracardiac obliteration of the left atrial appendage for stroke risk reduction in atrial fibrillation. J Am Coll Cardiol, 2003, 42(7): 1249-1252.
20.	Madden JL. Resection of the left auricular appendix; a prophylaxis for recurrent arterial emboli. J Am Med Assoc, 1949, 140(9): 769-772.
21.	Inoue T, Suematsu Y. Left atrial appendage resection can be performed minimally invasively with good clinical and echocardiographic outcomes without any severe risk. Eur J Cardiothorac Surg, 2018, 54(1): 78-83.
22.	Lee CH, Kim JB, Jung SH, et al. Left atrial appendage resection versus preservation during the surgical ablation of atrial fibrillation. Ann Thorac Surg, 2014, 97(1): 124-132.
23.	Roth P, Rahimi A, Boening A. The pericardium-reinforced technique of amputation of the left atrial appendage: Quick, safe, and simple. Ann Thorac Surg, 2010, 90(1): e11-13.
24.	Mahmood E, Matyal R, Mahmood F, et al. Impact of left atrial appendage exclusion on short-term outcomes in isolated coronary artery bypass graft surgery. Circulation, 2020, 142(1): 20-28.
25.	Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2024, 149(1): e1-e156.1-156.
26.	Crystal E, Lamy A, Connolly SJ, et al. Left Atrial Appendage Occlusion Study (LAAOS): A randomized clinical trial of left atrial appendage occlusion during routine coronary artery bypass graft surgery for long-term stroke prevention. Am Heart J, 2003, 145(1): 174-178.
27.	Healey JS, Crystal E, Lamy A, et al. Left Atrial Appendage Occlusion Study (LAAOS): Results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke. Am Heart J, 2005, 150(2): 288-293.
28.	Moreira-Pinto J, Ferreira A, Miranda A, et al. Left atrial appendage ligation with single transthoracic port assistance: A study of survival assessment in a porcine model (with videos). Gastrointest Endosc, 2012, 75(5): 1055-1061.
29.	Gianni C, Di Biase L, Trivedi C, et al. Clinical implications of leaks following left atrial appendage ligation with the LARIAT Device. JACC Cardiovasc Interv, 2016, 9(10): 1051-1057.
30.	Aryana A, Singh SK, Singh SM, et al. Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization. Heart Rhythm, 2015, 12(7): 1431-1437.
31.	García-Fernández MA, Pérez-David E, Quiles J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: A transesophageal echocardiographic study. J Am Coll Cardiol, 2003, 42(7): 1253-1258.
32.	Katz ES, Tsiamtsiouris T, Applebaum RM, et al. Surgical left atrial appendage ligation is frequently incomplete: A transesophageal echocardiograhic study. J Am Coll Cardiol, 2000, 36(2): 468-471.
33.	Ohtsuka T, Nonaka T, Hisagi M, et al. Thoracoscopic stapler-and-loop technique for left atrial appendage closure in nonvalvular atrial fibrillation: Mid-term outcomes in 201 patients. Heart Rhythm, 2018, 15(9): 1314-1320.
34.	Ueberham L, Dagres N, Potpara TS, et al. Pharmacological and non-pharmacological treatments for stroke prevention in patients with atrial fibrillation. Adv Ther, 2017, 34(10): 2274-2294.
35.	Salzberg SP, Gillinov AM, Anyanwu A, et al. Surgical left atrial appendage occlusion: Evaluation of a novel device with magnetic resonance imaging. Eur J Cardiothorac Surg, 2008, 34(4): 766-770.
36.	Ailawadi G, Gerdisch MW, Harvey RL, et al. Exclusion of the left atrial appendage with a novel device: Early results of a multicenter trial. J Thorac Cardiovasc Surg, 2011, 142(5): 1002-1009.
37.	Beaver TM, Hedna VS, Khanna AY, et al. Thoracoscopic ablation with appendage ligation versus medical therapy for stroke prevention: A proof-of-concept randomized trial. Innovations (Phila), 2016, 11(2): 99-105.
38.	Park-Hansen J, Holme SJV, Irmukhamedov A, et al. Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: the LAACS randomized study. J Cardiothorac Surg, 2018, 13(1): 53.
39.	Abdel Mahamoud O, Xu S, Qian Y. TEE, CT or Both When Assessing the Efficacy of Different Left Atrial Appendage Closure Techniques? JTCVS Techniques, 2024.
40.	Caliskan E, Sahin A, Yilmaz M, et al. Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery. Europace, 2018, 20(7): e105-e114.
41.	Starck CT, Steffel J, Emmert MY, et al. Epicardial left atrial appendage clip occlusion also provides the electrical isolation of the left atrial appendage. Interact Cardiovasc Thorac Surg, 2012, 15(3): 416-418.
42.	Heuts S, H Heijmans J, La Meir M, et al. Does left atrial appendage exclusion by an epicardial clipinfluence left atrial hemodynamics? Pilot results of invasive intra-cardiac measurements. J Atr Fibrillation, 2021, 14(1): 20200479.
43.	Rhee Y, Park SJ, Lee JW. Epicardial left atrial appendage clip occlusion in patients with atrial fibrillation during minimally invasive cardiac surgery. J Thorac Cardiovasc Surg, 2023, 166(2): 468-474.
44.	Petersen J, Böning H, Yildirim S, et al. Efficacy of four different left atrial appendage closure techniques during cardiac surgery-A transesophageal echocardiography follow-up study. JTCVS Tech, 2024, 26: 43-49.
45.	Yoshimoto A, Suematsu Y, Kurahashi K, et al. Early and middle-term results and anticoagulation strategy after left atrial appendage exclusion using an epicardial clip device. Ann Thorac Cardiovasc Surg, 2021, 27(3): 185-190.

1. Kimura T, Takatsuki S, Miyoshi S, et al. Pericardial endoscopy-guided left atrial appendage ligation: A pilot study in a canine model. Circ Cardiovasc Interv, 2014, 7(6): 844-850.
2. Murtaza G, Boda U, Turagam MK, et al. Risks and benefits of removal of the left atrial appendage. Curr Cardiol Rep, 2020, 22(11): 129.
3. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 2014, 64(21): e1-76.
4. Kanderian AS, Gillinov AM, Pettersson GB, et al. Success of surgical left atrial appendage closure: Assessment by transesophageal echocardiography. J Am Coll Cardiol, 2008, 52(11): 924-929.
5. Ramlawi B, Abu Saleh WK, Edgerton J. The left atrial appendage: Target for stroke reduction in atrial fibrillation. Methodist Debakey Cardiovasc J, 2015, 11(2): 100-103.
6. Wolf PA, Dawber TR, Thomas HE, et al. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: The Framingham study. Neurology, 1978, 28(10): 973-977.
7. Krahn AD, Manfreda J, Tate RB, et al. The natural history of atrial fibrillation: Incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med, 1995, 98(5): 476-484.
8. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke, 1991, 22(8): 983-988.
9. Price MJ, Valderrábano M. Left atrial appendage closure to prevent stroke in patients with atrial fibrillation. Circulation, 2014, 130(2): 202-212.
10. Ahmed A, Pothineni NVK, Singh V, et al. Long-term imaging and clinical outcomes of surgical left atrial appendage occlusion with AtriClip. Am J Cardiol, 2023, 201: 193-199.
11. Kreidieh B, Rojas F, Schurmann P, et al. Left atrial appendage remodeling after lariat left atrial appendage ligation. Circ Arrhythm Electrophysiol, 2015, 8(6): 1351-1358.
12. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg, 1996, 61(2): 755-759.
13. Johnson WD, Ganjoo AK, Stone CD, et al. The left atrial appendage: Our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg, 2000, 17(6): 718-722.
14. Lakkireddy D, Sridhar Mahankali A, Kanmanthareddy A, et al. Left atrial appendage ligation and ablation for persistent atrial fibrillation: The LAALA-AF registry. JACC Clin Electrophysiol, 2015, 1(3): 153-160.
15. Yamada T, McElderry HT, Allison JS, et al. Focal atrial tachycardia originating from the epicardial left atrial appendage. Heart Rhythm, 2008, 5(5): 766-767.
16. Di Biase L, Burkhardt JD, Mohanty P, et al. Left atrial appendage: An underrecognized trigger site of atrial fibrillation. Circulation, 2010, 122(2): 109-118.
17. Güner A, Kalçık M, Gündüz S, et al. The relationship between incomplete surgical obliteration of the left atrial appendage and thromboembolic events after mitral valve surgery (from the ISOLATE Registry). J Thromb Thrombolysis, 2021, 51(4): 1078-1089.
18. Auer J, Lamm G. Left atrial appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med, 2021, 385(11): 1053.
19. Blackshear JL, Johnson WD, Odell JA, et al. Thoracoscopic extracardiac obliteration of the left atrial appendage for stroke risk reduction in atrial fibrillation. J Am Coll Cardiol, 2003, 42(7): 1249-1252.
20. Madden JL. Resection of the left auricular appendix; a prophylaxis for recurrent arterial emboli. J Am Med Assoc, 1949, 140(9): 769-772.
21. Inoue T, Suematsu Y. Left atrial appendage resection can be performed minimally invasively with good clinical and echocardiographic outcomes without any severe risk. Eur J Cardiothorac Surg, 2018, 54(1): 78-83.
22. Lee CH, Kim JB, Jung SH, et al. Left atrial appendage resection versus preservation during the surgical ablation of atrial fibrillation. Ann Thorac Surg, 2014, 97(1): 124-132.
23. Roth P, Rahimi A, Boening A. The pericardium-reinforced technique of amputation of the left atrial appendage: Quick, safe, and simple. Ann Thorac Surg, 2010, 90(1): e11-13.
24. Mahmood E, Matyal R, Mahmood F, et al. Impact of left atrial appendage exclusion on short-term outcomes in isolated coronary artery bypass graft surgery. Circulation, 2020, 142(1): 20-28.
25. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2024, 149(1): e1-e156.1-156.
26. Crystal E, Lamy A, Connolly SJ, et al. Left Atrial Appendage Occlusion Study (LAAOS): A randomized clinical trial of left atrial appendage occlusion during routine coronary artery bypass graft surgery for long-term stroke prevention. Am Heart J, 2003, 145(1): 174-178.
27. Healey JS, Crystal E, Lamy A, et al. Left Atrial Appendage Occlusion Study (LAAOS): Results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke. Am Heart J, 2005, 150(2): 288-293.
28. Moreira-Pinto J, Ferreira A, Miranda A, et al. Left atrial appendage ligation with single transthoracic port assistance: A study of survival assessment in a porcine model (with videos). Gastrointest Endosc, 2012, 75(5): 1055-1061.
29. Gianni C, Di Biase L, Trivedi C, et al. Clinical implications of leaks following left atrial appendage ligation with the LARIAT Device. JACC Cardiovasc Interv, 2016, 9(10): 1051-1057.
30. Aryana A, Singh SK, Singh SM, et al. Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization. Heart Rhythm, 2015, 12(7): 1431-1437.
31. García-Fernández MA, Pérez-David E, Quiles J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: A transesophageal echocardiographic study. J Am Coll Cardiol, 2003, 42(7): 1253-1258.
32. Katz ES, Tsiamtsiouris T, Applebaum RM, et al. Surgical left atrial appendage ligation is frequently incomplete: A transesophageal echocardiograhic study. J Am Coll Cardiol, 2000, 36(2): 468-471.
33. Ohtsuka T, Nonaka T, Hisagi M, et al. Thoracoscopic stapler-and-loop technique for left atrial appendage closure in nonvalvular atrial fibrillation: Mid-term outcomes in 201 patients. Heart Rhythm, 2018, 15(9): 1314-1320.
34. Ueberham L, Dagres N, Potpara TS, et al. Pharmacological and non-pharmacological treatments for stroke prevention in patients with atrial fibrillation. Adv Ther, 2017, 34(10): 2274-2294.
35. Salzberg SP, Gillinov AM, Anyanwu A, et al. Surgical left atrial appendage occlusion: Evaluation of a novel device with magnetic resonance imaging. Eur J Cardiothorac Surg, 2008, 34(4): 766-770.
36. Ailawadi G, Gerdisch MW, Harvey RL, et al. Exclusion of the left atrial appendage with a novel device: Early results of a multicenter trial. J Thorac Cardiovasc Surg, 2011, 142(5): 1002-1009.
37. Beaver TM, Hedna VS, Khanna AY, et al. Thoracoscopic ablation with appendage ligation versus medical therapy for stroke prevention: A proof-of-concept randomized trial. Innovations (Phila), 2016, 11(2): 99-105.
38. Park-Hansen J, Holme SJV, Irmukhamedov A, et al. Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: the LAACS randomized study. J Cardiothorac Surg, 2018, 13(1): 53.
39. Abdel Mahamoud O, Xu S, Qian Y. TEE, CT or Both When Assessing the Efficacy of Different Left Atrial Appendage Closure Techniques? JTCVS Techniques, 2024.
40. Caliskan E, Sahin A, Yilmaz M, et al. Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery. Europace, 2018, 20(7): e105-e114.
41. Starck CT, Steffel J, Emmert MY, et al. Epicardial left atrial appendage clip occlusion also provides the electrical isolation of the left atrial appendage. Interact Cardiovasc Thorac Surg, 2012, 15(3): 416-418.
42. Heuts S, H Heijmans J, La Meir M, et al. Does left atrial appendage exclusion by an epicardial clipinfluence left atrial hemodynamics? Pilot results of invasive intra-cardiac measurements. J Atr Fibrillation, 2021, 14(1): 20200479.
43. Rhee Y, Park SJ, Lee JW. Epicardial left atrial appendage clip occlusion in patients with atrial fibrillation during minimally invasive cardiac surgery. J Thorac Cardiovasc Surg, 2023, 166(2): 468-474.
44. Petersen J, Böning H, Yildirim S, et al. Efficacy of four different left atrial appendage closure techniques during cardiac surgery-A transesophageal echocardiography follow-up study. JTCVS Tech, 2024, 26: 43-49.
45. Yoshimoto A, Suematsu Y, Kurahashi K, et al. Early and middle-term results and anticoagulation strategy after left atrial appendage exclusion using an epicardial clip device. Ann Thorac Cardiovasc Surg, 2021, 27(3): 185-190.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesEffect of the surgical strategies of left atrial appendage on stroke prevention in patients with atrial fibrillation

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