Current review
Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation

https://doi.org/10.1016/0003-4975(95)00887-XGet rights and content

Background.

Left atrial appendage obliteration was historically ineffective for the prevention of postoperative stroke in patients with rheumatic atrial fibrillation who underwent operative mitral valvotomy. It is, however, a routine part of modern “curative” operations for nonrheumatic atrial fibrillation, such as the maze and corridor procedures.

Methods.

To assess the potential of left atrial appendage obliteration to prevent stroke in nonrheumatic atrial fibrillation patients, we reviewed previous reports that identified the etiology of atrial fibrillation and evaluated the presence and location of left atrial thrombus by transesophageal echocardiography, autopsy, or operation.

Results.

Twenty-three separate studies were reviewed, and 446 of 3,504 (13%) rheumatic atrial fibrillation patients, and 222 of 1,288 (17%) nonrheumatic atrial fibrillation patients had a documented left atrial thrombus. Anticoagulation status was variable and not controlled for. Thrombi were localized to, or were present in the left atrial appendage and extended into the left atrial cavity in 254 of 446 (57%) of patients with rheumatic atrial fibrillation. In contrast, 201 of 222 (91%) of nonrheumatic atrial fibrillation-related left atrial thrombi were isolated to, or originated in the left atrial appendage (p < 0.0001).

Conclusions.

These data suggest that left atrial appendage obliteration is a strategy of potential value for stroke prophylaxis in nonrheumatic atrial fibrillation.

References (59)

  • HwangJ et al.

    Reappraisal by transesophageal echocardiography of the significance of left atrial thrombi in the prediction of systemic arterial embolization in rheumatic mitral valve disease

    Am J Cardiol

    (1992)
  • SharmaS et al.

    Chest radiographs are unreliable in predicting thrombi in the left atrium or its appendage in rheumatic mitral stenosis

    Clin Radiol

    (1991)
  • StoddardMF et al.

    Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: a transesophageal echocardiographic study

    J Am Coll Cardiol

    (1995)
  • VignaC et al.

    Frequency of left atrial thrombi by transesophageal echocardiography in idiopathic and in ischemic dilated cardiomyopathy

    Am J Cardiol

    (1992)
  • SiostrzonekP et al.

    Hemodynamic and hemorrheologic determinants of left atrial spontaneous echo contrast and thrombus formation in patients with idiopathic dilated cardiomyopathy

    Am Heart J

    (1993)
  • GlowerDD et al.

    Performance status and outcome after coronary artery bypass grafting in persons aged 80 to 93 years

    Am J Cardiol

    (1992)
  • CameronA et al.

    Prevalence and significance of atrial fibrillation in coronary artery disease (CASS Registry)

    Am J Cardiol

    (1988)
  • FryeRL et al.

    Stroke in coronary artery bypass graft surgery: an analysis of the CASS experience

    The participants in the Coronary Artery Surgery Study

    Int J Cardiol

    (1992)
  • CreswellLL et al.

    Hazards of postoperative atrial arrhythmias

    Ann Thorac Surg

    (1993)
  • CoxJL

    A perspective of postoperative atrial fibrillation in cardiac operations

    Ann Thorac Surg

    (1993)
  • DiSesaVJ et al.

    Ligation of the left atrial appendage using an automatic surgical stapler

    Ann Thorac Surg

    (1988)
  • MaddenJL

    Resection of the left auricular appendix

    JAMA

    (1948)
  • BaileyCP et al.

    Commissurotomy for mitral stenosis: technique for prevention of cerebral complications

    JAMA

    (1952)
  • BelcherJR et al.

    Systemic embolism and left auricular thrombosis in relation to mitral valvotomy

    Br Med J

    (1955)
  • JordanRA et al.

    Mural thrombosis and arterial embolism in mitral stenosis

    Circulation

    (1951)
  • CoxJL

    Surgical treatment of atrial fibrillation

    J Thorac Cardiovasc Surg

    (1992)
  • FeinbergMS et al.

    Restoration of atrial function after the maze procedure for patients with atrial fibrillation: assessment by Doppler echocardiography

    Circulation

    (1994)
  • GuiraudonGM

    Surgical treatment of atrial fibrillation

    Herz

    (1993)
  • WolfPA et al.

    Atrial fibrillation as an independent risk factor for stroke: the Framingham study

    Stroke

    (1991)
  • Cited by (1322)

    View all citing articles on Scopus
    View full text