The Left Atrial Appendage “Lid”: Results of a novel tension-free endocardial exclusion technique
Objective: Current surgical techniques of left atrial appendage exclusion for atrial fibrillation (AF) have significant failure rates in the published literature, with long-term thromboemoblic events reported. In particular, internal ligation techniques have been reported as unsuccessful in 50% of patients, largely due to dehiscence from tension. We developed a novel technique of left atrial appendage (LAA) exclusion utilizing an internally placed, tension-free extracellular biomatrix patch that reduces the risk of residual substrate for thrombus development. Late clinical and echocardiography follow-up is described.
Methods: Retrospective review of consecutive patients undergoing surgical Maze procedure for AF at a single institution between October 2013 and July 2014. Following any mitral procedures, the LAA was inspected for thrombus and orifice size assessed. A piece of extracellular matrix biomaterial was sized to 150% of the orifice, anchored to the base of the appendage, and secured with running suture technique to exclude the LAA (Figure). Clinical and echocardiographic data were reviewed.
Results: 21 patients were identified (mean age 65 ±10, 29% male, NYHA 2.4 ±0.7). Preop AF type was new-onset in 3 (14%), paroxysmal in 2 (10%), persistent in 3 (14%), and permanent in 13 (62%). Four patients had LAA thrombus (19%). Concomitant procedures were CABG (n=4, 19%), mitral repair (n=14, 67%), mitral replacement (n=6, 29%), and tricuspid repair (n=7, 33%). The modified Maze procedure was biatrial in 16 (76%) and left-sided in the remainder. 30-day and in-hospital mortality were 0%. Follow-up transesophageal echocardiography was performed in 11 patients (52%) at a mean of 3.3 months. The failure rate was 18%, with residual flow that was mild or greater into the LAA in two patients. Of these failures, one patient had residual LAA thrombus. At mean followup period of 5.6 months (n=17, 81%), no patients had a thromboembolic episode and 5 (29%) are on anticoagulants
Conclusions: The technique utilized in this case series demonstrates a lower rate of LAA exclusion failure than traditional techniques. Continued development of this technique with adjuncts such as external ligation may result in improved results; further study is needed.