Current State of Surgical Left Atrial Appendage Exclusion

Edgerton, James R.

doi:10.1016/j.ccep.2019.10.001

Cited by 4 publications

(2 citation statements)

References 40 publications

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“…Devices for RF ablation of the atrial wall have made the maze procedure faster, easier, and more widespread. However, the clinical outcome of the RF modification of the operation is worse than the outcome of the classic maze procedure [ 15 , 16 ] .…”

Section: Discussionmentioning

confidence: 99%

The Technology of Homogeneous Scar Tissue Creating as a Result of Ablation of the Atrial Wall with a Radiofrequency Bipolar Clamp: an Experimental and Clinical Study

Vachev¹,

Zabozlaev²,

Voronin³

et al. 2023

Braz J Cardiovasc Surg

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Introduction The objective of this study was to develop a radiofrequency ablation technique to create a homogeneous scar tissue in the atrial myocardium. Methods In the double-blinded morphological stage of the study, the left atrial appendage was used as an anatomical model to investigate the efficacy of one experimental and two conventional techniques to create ablation lines. Then, these lines were studied by morphologists. The clinical stage involved investigation of the outcomes of the developed technique for creation of ablation lines. During thoracoscopic radiofrequency fragmentation of the left atrium, all ablation lines were created using the experimental radiofrequency technique. Results In all histological sections of ablation lines created using the criterion of “steady decrease in the time to transmurality”, there were no intact (viable) cells, in contrast to the other two conventional methods, i.e., a homogeneous scar of the atrial wall. Investigation of clinical efficacy of this developed technique revealed recurrent atrial fibrillation only in six of 137 patients (4.4%) at median follow-up time of 36 (10; 58) months. None of the patients developed specific complications (wall perforation or bleeding). According to intracardiac mapping performed after the end of the blind period, the sources of atrial fibrillation in these six patients were outside the radiofrequency ablation zone (perimitral or in the right atrium). Conclusion A steady decrease in the time to transmurality should be considered as the priority intraoperative criterion for the formation of a homogeneous scar during radiofrequency ablation of the left atrium wall using a bipolar ablation clamp.

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Section: Discussionmentioning

confidence: 99%

The Technology of Homogeneous Scar Tissue Creating as a Result of Ablation of the Atrial Wall with a Radiofrequency Bipolar Clamp: an Experimental and Clinical Study

Vachev¹,

Zabozlaev²,

Voronin³

et al. 2023

Braz J Cardiovasc Surg

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“…Incomplete occlusion may be more dangerous than no intervention; the same study found thrombus in 41% unsuccessfully excluded appendages, with restricted flow through a narrowed neck likely predisposing to stasis and thromboembolism [16]. External clip devices (Atriclip, AtriCure, West Chester, OH) may have a success rate as high as 98%, inducing appendage tissue necrosis and mimicking excision [17]. The ATLAS trial (AtriClip LAA Exclusion Concomitant to Structural Heart Procedures, NCT02701062) currently underway seeks to randomize 2000 patients with history of AF undergoing CABG or valve surgery to AtriClip vs. medical management (anticoagulation).…”

Section: Key Pointsmentioning

confidence: 99%

Surgical left atrial appendage occlusion with concomitant cardiac surgical procedures: exacerbating heart failure or preventing stroke

Mandell

Boisen

2022

Current Opinion in Anaesthesiology

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Purpose of reviewThe left atrial appendage (LAA) is a common source of thromboembolic stroke in patients with atrial fibrillation. Current guidelines recommend consideration of surgical LAA occlusion concomitant with other cardiac surgical procedures based mostly on observational data and a few small trials. Recently published results of several large retrospective studies and one prospective trial are reviewed herein. Recent findingsLarge retrospective studies using quality and administrative databases show mixed results with regard to efficacy of surgical LAA occlusion in preventing stroke, although most showed stroke reduction in patients with a history of atrial fibrillation (AF). Safety concerns have been raised based on nonrandomized data suggesting increased complications. A recent large, multicenter international randomized study with 3-year follow-up demonstrated significant reduction in stroke following LAA occlusion with no differences in death or heart failure exacerbations. SummaryMost patients with AF undergoing another cardiac surgical procedure should be considered for concomitant LAA occlusion as part of a heart team discussion. The choice of surgical closure technique is critical. There is insufficient data to recommend LAA occlusion as an alternative to anticoagulation.

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