Atrial Appendage Ligation Research Articles

Pre-Operative Intracardiac Thrombus is Associated with Increased Risk of Stroke and Death in CF-LVAD Patients

Advanced heart failure predisposes patients to intracardiac thrombus (ICT) formation. There is a paucity of evidence examining the impact of pre-existing left atrial (LA) or left ventricular (LV) thrombi on post-operative outcomes in patients undergoing durable LVAD implantation. We retrospectively reviewed 525 LVAD patients (374 HMII, 151 HM3) from 2/2009 through 3/2019. Transthoracic echocardiography (TTE) within 1 month of implant, intra-operative transesophageal echocardiography (TEE), and operative reports were reviewed to identify patients with pre-existing ICT at the time of LVAD surgery. The primary outcome was a composite of stroke or death at 6 months. Of the 525 patients (age 58±1 years, 81.5% male, 46% ICM) who underwent device implantation during the study period, 41 (7.8%) had a pre-existing ICT (16 in LA, 22 in LV and 3 in both). Patients with ICT had higher mortality (24.4% vs. 9.3%; p=0.002) and higher stroke rate (17.1% vs. 7.6%; p=0.036) at 6 months compared to patients without thrombus. Survival free from stroke and freedom from stroke in the two groups is shown in Figure 1a and 1b. In a multivariable model including age, gender, history of stroke, history of atrial fibrillation/flutter, atrial appendage ligation, and device type, ICT was found to be the only independent predictor of death or stroke at 6 months (HR 2.07, 95% CI 1.10 - 3.89). No stroke or deaths occurred in the 7 HM3 patients who had ICT prior to surgery. Pre-existing ICT is associated with decreased survival free of stroke following LVAD implantation. Additional studies are warranted to assess the optimal risk stratification and management of these patients.

Percutaneous pericardial access for electrophysiological studies in patients with prior cardiac surgery: approach and understanding the risks

ABSTRACTIntroduction: The number of procedures for which percutaneous pericardial access is used for has gradually increased since its initial description, and now includes mapping/ablation, atrial appendage ligation and pericardial biopsy.Areas covered: Successful percutaneous pericardial access is predicated on having a thorough understanding of regional anatomy, indications for attempting pericardial puncture and potential complications with appropriate management which are highlighted in this review. In addition, we will discuss the access technique itself, provide tips and pitfalls and highlight future directions with an emphasis on patients with prior cardiac surgery.Expert commentary: Percutaneous epicardial access, especially in patients with prior cardiac surgery, is associated with significant complications and therefore meticulous preparation is required. Even in experienced centers, unusual circumstances may be crossed.

Retrospective Analysis of Left Atrial Enlargement after Surgical Left Atrial Appendage Amputation or Ligation

Retrospective Analysis of Left Atrial Enlargement after Surgical Left Atrial Appendage Amputation or Ligation

Thoracoscopic Ablation With Appendage Ligation Versus Medical Therapy for Stroke Prevention: A Proof-of-Concept Randomized Trial.

Atrial fibrillation (AF) has a demonstrable effect on quality of life (QOL). Recurrent stroke occurs in 10% of patients with AF. The objective of this study was to demonstrate proof of concept that thoracoscopic pulmonary vein isolation and atrial appendage ligation (TPVIAL) could prevent recurrent stroke and could potentially improve QOL in patients with AF with a previous stroke. The study was a National Institutes of Health-funded single-center proof-of-concept design that randomized 23 patients with AF-related stroke to TPVIAL (n = 12) or to medical management (n = 11). Quality of life was the primary outcome variable; secondary end points included restoration of rhythm, recurrent stroke, and surgical morbidity. Quality-of-life subscores at 3 and 6 months revealed improvements in energy and decreases in fatigue in the TPVIAL arm [baseline, 33 (19.8); 3 months, 49.5 (20.6), P = 0.01; 6 months, 55.5 (14.4), P = 0.03]. At 12-month follow-up, there were no recurrent strokes in the TPVIAL group. In the medically treated arm, two patients at 6 months (P = 0.22) and three total patients at 12 months (P = 0.09) had recurrent ischemic stroke. There was one death in the medical management arm. In the TPVIAL arm, no AF recurrence occurred in patients with paroxysmal AF, and one patient had recurrence of persistent and long-standing AF. Seven patients in the TPVIAL arm discontinued warfarin therapy for secondary stroke prevention. This small proof-of-concept study showed that TPVIAL improved QOL on two subscores and restored normal sinus rhythm in all but one patient, and it showed the potential to prevent secondary stroke. A larger study will be needed.

Thoracoscopic Pulmonary Vein Isolation and Atrial Appendage Ligation (TPVIAL) versus Medical Management in Atrial Fibrillation Patients with Prior Stroke (P1.126)

Thoracoscopic Pulmonary Vein Isolation and Atrial Appendage Ligation (TPVIAL) versus Medical Management in Atrial Fibrillation Patients with Prior Stroke (P1.126)

Clinical Experience with Permanent Atrioventricular Sequential Pacing

In a 23-month period, we implanted 26 permanent atrioventricular (AV) sequential pacing units in 11 women and 15 men ranging from 37 to 85 years old (mean, 68 years). Indications for pacing were complete heart block in 12 patients and sick sinus syndrome in 14 patients. Cardiac index, using standard thermodilution techniques, was determined in 9 patients during ventricular pacing and AV sequential pacing at constant heart rate. Atrioventricular sequential pacing was superior in all patients, with a mean increase in cardiac index of 22% ( p < 0.01). Complications of AV sequential pacing included the need to revise two pulse generator pockets due to the large size of the pulse generator. One transvenous atrial lead displacement occurred in a patient who had previously undergone right atrial appendage ligation at open-heart operation. No failures of pacing or sensing occurred during 279 patient-paced months. The theoretical hemodynamic advantage of AV sequential pacing has been confirmed in this clinical trial. Experience with electrode placement and improvements in pulse generator design should aid in eliminating complications with this pacing modality.