Assessing the Immediate and Sustained Effectiveness of Circular Epicardial Surgical Ligation of the Left Atrial Appendage

Abstract

Obliterating the left atrial appendage from systemic circulation in patients with atrial fibrillation has been proposed to reduce thromboembolic events. The goal of this study was to assess the effectiveness of a circular method of epicardial surgical ligation in obliterating the left atrial appendage and maintaining sustained exclusion. Patients with permanent atrial fibrillation and an indication for elective cardiac surgery were enrolled. All patients underwent preoperative cardiac gated computerized tomography (CT) and transesophageal echocardiography (TEE). During the cardiac procedure circular ligation of the appendage was performed. Twelve patients, mean (SD) age 65 (12) years completed the study. Intraoperative TEE demonstrated all patients (12/12) had complete postligation occlusion of the left atrial appendage. At three-month follow-up, cardiac gated CT demonstrated that 75% (9/12) of the patients had communication of contrast dye from the left atrial appendage to body of left atrium. Left atrial appendage orifice area and volume were reduced from mean (SD) (5.5 cm(2) [1.8] to 0.5 cm(2) [0.4] p = 0.002) and (14.0 cm(3) [8.3] to 2.7 cm(3) [1.3] p = .005) postligation, respectively. No clinically significant thromboembolic events were reported. Epicardial suture ligation of the left atrial appendage resulted in successful intra-operative exclusion on TEE; however, a significant portion of patient's demonstrated communication of contrast on CT. This is suggestive of incomplete long-term exclusion. The clinical significance of reduction in left atrial appendage orifice area and volume with a persistent communication requires further study.