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Epicardial Surgical Ligation of the Left Atrial Appendage Is Safe, Reproducible, and Effective by Transesophageal Echocardiographic Follow-up

Zapolanski, Alex MD*; Johnson, Christopher K. BS*; Dardashti, Omid MD*; O’Keefe, Ryan M.*; Rioux, Nancy RN*; Ferrari, Giovanni PhD*†; Shaw, Richard E. PhD*; Brizzio, Mariano E. MD*; Grau, Juan B. MD*†

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: September/October 2013 - Volume 8 - Issue 5 - p 371–375
doi: 10.1097/IMI.0000000000000022
Original Articles

Objective The left atrial appendage (LAA) is the source of 90% of thrombi in patients with atrial fibrillation. Our double LAA ligation (LLAA) technique was shown to be 96% successful in a small study. However, the outcomes of these patients have yet to be compared with a set of nonligated patients.

Methods From 2005 to 2012, a total of 808 patients received LAA using our double ligation technique using both a polydioxanone (PDS) II endosnare and a running 4-0 Prolene pledgeted suture. The 30-day outcomes of these patients were compared with that of nonligated patients. Fifty-six of the ligated patients had a postoperative transesophageal echocardiography (TEE). An echocardiographer reviewed the follow-up TEEs for LAA remnant and/or residual flow into the LAA using color Doppler imaging. The patients with LAA flow and/or remnant depth of 1 cm or greater were deemed to have an unsuccessful exclusion.

Results The ligated group had a trend of less postoperative atrial fibrillation (19.4% vs 22.9%, P = 0.07) and an overall significantly lower in-hospital mortality (0.7% vs 3.0%, P < 0.001) and lower 30-day mortality (0.7% vs 3.4%, P < 0.0001). The LAA was successfully excluded in 53 (94.7%) of the 56 patients with TEE.

Conclusions Double LAA ligation correlates with lower rates of in-hospital and 30-day mortality. This advantage comes without an increase in perioperative complications. This technique can easily be performed off or on pump, is very reproducible, and comes at a very low cost compared with LAA occlusion devices. Stroke has a multifactorial etiology; successful LLAA removes one potential source of thrombi perioperatively and in the long-term.

From *The Valley Columbia Heart Center, Columbia University College of Physicians and Surgeons, Ridgewood, NJ USA; and †The University of Pennsylvania School of Medicine, Glenolden, PA USA.

Accepted for publication September 18, 2013.

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Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Juan B. Grau, MD, The Valley Heart and Vascular Institute, 223 North Van Dien Ave, Ridgewood, NJ USA. E-mail:

©2013 by the International Society for Minimally Invasive Cardiothoracic Surgery