Herzschrittmachertherapie +

Elektrophysiologie

Schwerpunkt
Herzschr Elektrophys
https://doi.org/10.1007/s00399-022-00903-6
Received: 11 July 2022
Surgical atrial appendage
Accepted: 11 September 2022
closure: time for a randomized
© The Author(s), under exclusive licence to
Springer Medizin Verlag GmbH, ein Teil von
Springer Nature 2022
study
Magdalena Rufa · Nora Göbel · Ulrich F. W. Franke
Department of Cardiovascular Surgery, Robert Bosch Hospital Stuttgart, Stuttgart, Germany

Abstract

In this article Atrial fibrillation (AF) is the most common arrhythmia and is assumed to affect more
than 30 million people worldwide. Studies report that the left atrial appendage
– Introduction (LAA) plays an important role in thrombus formation and is considered the embolic
– Current situation source in 90% of affected patients with non-valvular and 57% with valvular AF. Oral
– Morphology, function, and importance of anticoagulants have been the standard of care for stroke prevention in patients with
the LAA AF for decades. However, bleeding complications and noncompliance are barriers
– Surgical techniques to effective embolic protection. Therefore, as an alternative to conventional anti-
– Literature reports thrombotic therapy, surgical LAA occlusion, which may lead to a reduced risk of
– Practical conclusion thromboembolism, has received increasing attention. However, the procedure can
be associated with additional risks such as prolonged operation time, damage to the
circumflex coronary artery, and incomplete LAA occlusion. This review discusses some
of the observational studies that have examined the impact of LAA occlusion on stroke,
the LAAOS III (Left Atrial Appendage Occlusion Study) trial, which provided definitive
evidence for the benefit of surgical LAA occlusion on ischemic stroke, which surgical
methods are safe and effective for LAA occlusion, and whether oral anticoagulation can
be stopped after surgical removal of the LAA.

Keywords
Atrial fibrillation · Left atrial appendage · Occlusion · Cardiac surgery · Anticoagulation therapy

Introduction Current situation

Atrial fibrillation (AF) is the most common The LAAOS III study (Left Atrial Appendage
cardiac arrhythmia (2% of the general pop- Occlusion Study), a large randomized con-
ulation, 20% in those over 80 years of trolled trial, recently demonstrated that
age) [1]. The most serious complications concomitant left atrial appendage oc-
of AF include thromboembolic stroke and clusion (LAAO) in patients with AF and
heart failure caused by tachyarrhythmia. a CHA2DS2-VASc score ≥ 2 undergoing car-
Up to 50% of patients requiring cardiac diac surgery for another indication reduces
surgery have a history of AF. The left atrial the risk of ischemic stroke or systemic
appendage (LAA) is considered the source embolism on top of oral anticoagulation
of 90% of the embolisms in non-valvular by 33% [4].
AF and 57% of the embolisms in valvular According to the 2020 European So-
AF [2]. Oral anticoagulants have been the ciety of Cardiology (ESC) guidelines for
standard of care for stroke prevention in the management of AF developed in col-
AF patients for decades. It is projected that laboration with the European Association
strokes related to AF will markedly increase for Cardio-Thoracic Surgery (EACTS), sur-
in the future unless effective treatment gical occlusion or exclusion of the LAA
strategies are implemented [3]. may be considered for stroke prevention in
AF patients undergoing cardiac surgery or
thoracoscopic AF surgery (Class IIb, Level
Scan QR code & read article online of Evidence B) [1]. The “The Society of

Herzschrittmachertherapie + Elektrophysiologie 1
Schwerpunkt
Table 1 Overview of the different surgical techniques for surgical left atrial appendage exclusion or excision
Surgical technique Epicardial Endocardial Exclusion Excision Concomitant Applicable in Applicable for
open-heart minimally in- stand-alone min-
surgery vasive mitral imally invasive
surgery surgery
Simple or double layer x x x – x x –
suture
Purse string suture x x x – x x –
Ligation loops x – x – x – –
Resection and suture x x – x x x –
Stapler x – – x x (x) x
AtriClip x – x – x (x) x

Thoracic Surgeons 2017 Clinical Practice Surgical techniques 4. Resection and suture
Guidelines for the Surgical Treatment of The LAA is excised at the neck and then
Atrial Fibrillation” stipulates that at the There is a variety of surgical techniques the opening is over-sewn in multiple fash-
time of concomitant cardiac operations for occlusion of the LAA. . Table 1 shows ions (running/mattress sutures), single/
in patients with AF, it is reasonable to an overview of the different surgical tech- double layer, with or without felt pledget
surgically manage the LAA for longitu- niques for LAA treatment. reinforcement [8].
dinal thromboembolic morbidity preven-
tion (Class IIA, Level C expert opinion) [5]. 1. Epicardial suture 5. Stapler excision
However, the LAAOS III Study irrefutably Simple suture ligation: a suture is placed This technique utilizes a cutting or non-
showed the benefit of concomitant LAA epicardially around the neck at the base cutting surgical stapler; a pericardial strip
occlusion to prevent stroke, which may of the LAA and tied down excluding the can be used to buttress the staple line [10].
change the recommendation for surgical LAA [7].
LAAO in the future guidelines. Purse string suture exclusion: a Teflon 6. AtriClip
felt pledget-reinforced purse string suture The AtriClip (Atricure, Dayton, Ohio, US) is
Morphology, function, and is placed across the base of the LAA en- an LAA exclusion system for the occlusion
importance of the LAA circling the base and tied down [8]. of the LAA under direct visualization in
open-heart surgery or video-assisted de-
The LAA is a tubular structure attached 2. Endocardial suture ployment in thoracoscopic surgery. This
to the left atrium (LA). It varies widely in Single- or double-layer endocardial suture device holds the strongest evidence avail-
terms of size and shape. Using computed exclusion: runningand/or mattress sutures able. This parallel, self-closing clamp is
tomography and cardiac magnetic reso- are placed from the open LA at the orifice designed with a cloth-covering that ex-
nance imaging, LAA morphology was clas- of the LAA in a single- or double-layer erts uniform pressure at the base of the
sified into four shapes. From most to least fashion [8]. LAA. The goal is to exert a high occlusion
common these are: chicken wing, cactus, Invagination and double suture tech- pressure that results in atrophy of the LAA
windsock, and cauliflower [3]. The LAA nique: through a left atriotomy the LAA [3].
has neurohormonal and reservoir func- is completely invaginated into the LA and Due to the high incidence of AF in
tions. It shares its embryological origin a purse string suture is placed at the base patients with mitral valve regurgitation,
with the pulmonary veins (PV) and is an of the LAA encircling its orifice. The purse there is a high demand for concomitant
underreported electrical focus site for non- string suture is tied up while the LAA is LAA closure in patients with minimally in-
PV AF. The discontinuity of myocardium as pulled outward or excised, and the suture vasive mitral surgery (MIMS). However, the
it transitions from LA to LAA has been pro- line is secured with a second running right-sided minithoracotomymakes access
posed as a potential substrate for arrhyth- suture [9]. to the LAA difficult. There are few reports
mia generation. Patients with persistent for epicardial stapler or clip application
AF have thicker interstitial collagen fibers 3. Ligation loops through the transverse sinus. Endocardial
than those in paroxysmal AF, a fact that is When using surgical ligation, first the techniques like LAA exclusion by running
shown to correlate with conduction abnor- epicardial base of the LAA is mobilized, or purse string sutures are predominantly
malities. During AF, Doppler flow velocity then a clamp is placed at the base of used. The authors achieved excellent re-
is reduced and the propensity for throm- the LAA and non-adsorbable ligatures are sults conducting complete endocardial re-
bus formation increases [6]. knotted sequentially at the base of the LAA. section at the base with a two-layer suture
line.
Stand-alone LAA closure without ar-
rhythmia surgery may be indicated in se-

2 Herzschrittmachertherapie + Elektrophysiologie
lected patients at high risk for stroke or derwent surgical LAAO was observed [14]. not to stand-alone surgical or endovascu-
systemic embolism necessitating oral anti- Overall, there was no difference in terms lar occlusion.
coagulation (OAC), but who are at high risk of reoperations for bleeding between the AtriClip use showed an excellent safety
for bleeding. For this procedure, the sta- LAAO and non-LAAO cohorts [14]. and durability profile in multiple studies
pler and the newest generation of AtriClip In a retrospective cohort study of [17, 18]. The AtriClip has the following the-
device can be used. 10,524 patients with AF undergoing car- oretical advantages over traditional surgi-
To date, surgical LAA occlusion is the diac surgery, surgical LAAO was associated cal excision: ability to reposition the de-
only procedure that demonstrated a re- with a significantly lower risk of readmis- vice, lower risk for tears and bleeding, and
duction in ischemic stroke risk in patients sion for thromboembolism at 3 years decreased left circumflex artery injury [3].
with AF, perhaps due to the fact that it (unadjusted, 4.2% vs. 6.2%; adjusted In a series of consecutive patients with
does not leave any device in contact with hazard ratio, 0.67) and lower rates of ischemic stroke and/or systemic emboliza-
the blood stream [4], contrasting to the all-cause mortality (unadjusted 17.3% tion in the absence of significant carotid
interventionally implanted occlusion de- vs. 23.9%, adjusted hazard ratio, 0.88) arterial stenosis, Labovitz and colleagues

Schwerpunkt
vices. when compared with no surgical LAAO found that 5% of patients in sinus rhythm
[15]. However, the authors do not specify demonstrated LAA thrombi [19]. Similarly,
Literature reports the surgical LAAO techniques used. Vigna and colleagues reported an atrial
Atti and colleagues published a very thrombus in 14% of patients with dilated
The epicardial or endocardial suture tech- large meta-analysis of 12 studies includ- cardiomyopathy who were in sinus rhythm
nique is often associated with incomplete ing a total of 40,107 patients. Of these, [20]. Therefore, these reports suggest that
occlusion. Failure to attain closure of 13,535 received surgical LAAO during the LAA may perhaps serve as a source of
the LAA led to the premature discon- cardiac surgery, while the remaining thromboembolism in the absence of AF
tinuation of the first randomized clinical 26,572 patients did not receive surgical [21]. This could be the rationale for the
trial in the field of surgical LAA closure, LAAO. Their main findings are the follow- ®
ATLAS (AtriClip Left Atrial Appendage Ex-
the LAAOS I pilot trial [11]. The trial ing: surgical LAAO was associated with clusion Concomitant to Structural Heart
included 77 coronary artery bypass graft lower rates of embolic events and stroke, Procedures) trial.
(CABG) patients with a risk factor for stroke and there was no significant difference in The ATLAS trial is a randomized open
(> 75 years, > 65 years and hypertension, the incidence of all-cause mortality, post- label study that includes patients without
previous stroke, AF) in whom LAA occlu- operative complications, or reoperations a documented history of AF, undergoing
sion was conducted by stapler or suture for bleeding between the two groups [16]. a valve or coronary artery bypass graft pro-
closure. Complete occlusion of the LAA LAAOS III was a multicenter trial that cedure with direct visual access to the LAA.
was achieved in only 45% (5/11) of cases randomly assigned patients with AF with The enrolled patients are randomized 2:1
using sutures (residual flow through the CHA2D2-VASc scores ≥ 2 who were under- (two with AtriClip to one without AtriClip).
suture line into the LAA) and in 72% going cardiac surgery for another indica- Subjects who develop post-operative AF
(24/33) using a stapler (residual stump tion to surgical LAAO (occlusion group) or and receive the AtriClip will be followed for
> 1 cm) [9]. On the other hand, LAAOS II no LAAO (no-occlusion group). All patients 365 days post index procedure. The pri-
included 51 patients in whom LAA oc- received the usual postoperative care in- mary objective of this study is to compare
clusion was achieved by stapler or cut cluding oral anticoagulants. At 3 years, the incidence and impact of postopera-
and sew, and at follow-up they presented 76.8% of the participants continued to re- tive AF among the two treatment arms.
a 100% success rate of occlusion [12]. ceive oral anticoagulants for AF. Stroke or A prespecified secondary analysis of this
Aryana and associates identified incom- systemic embolism (primary outcome) oc- trial is intended to evaluate the healthcare
pletely ligated LAAs and significant LAA curred in 4.8% in the occlusion group and resource utilization in each group. The first
stumps to be a predictor for ischemic stroke in 7% in the no-occlusion group, p = 0.001 results are expected later this year.
or systemic embolization [13]. Incomplete [4]. The benefit of surgical LAAO on stroke
occlusion carries a higher risk than no oc- prevention appeared to be an adjunct to Practical conclusion
clusion in relation to long-term throm- oral anticoagulation therapy. However,
boembolic events [13]. the study does not support surgical LAAO The two largest randomized trials—
A large meta-analysis of patients un- as a replacement for oral anticoagulation PROTECT-AF (WATCHMAN Left Atrial Ap-
dergoing concomitant surgical LAA occlu- therapy. The authors did not conduct an pendage System for Embolic Protection
sion by Tsai et al. showed significant re- analysis on whether all surgical closure in Patients with Atrial Fibrillation) and
ductions in stroke at 30 days (0.95% vs. methods were comparable, and they also PREVAIL (Watchmann LAA Closure Device
1.9%, p = 0.005) and at follow-up (1.4% did not examine whether occlusion was in Patients with Atrial Fibrillation Versus
vs. 4.1%, p = 0.01) in patients with AF un- sustained over follow-up. Furthermore, Long Term Warfarin Therapy)—showed
dergoing surgical LAA occlusion compared the findings from LAAOS III apply primarily percutaneous LAAO to be non-inferior to
with matched controls. In addition, a sig- to surgical occlusion of the appendage per- warfarin with respect to stroke rates and
nificant reduction in all-cause mortality formed as a concomitant procedure and embolic events [22, 23]. Following the
(1.9% vs. 5%, p = 0.0003) in those that un- success with percutaneous LAAO, there

Herzschrittmachertherapie + Elektrophysiologie 3
 Zusammenfassung

has been a resurgence of interest in sur- Chirurgischer Vorhofohrverschluss – Zeit für eine randomisierte Studie
gical LAAO, especially with the increase
in the aging population and the rising Vorhofflimmern ist die häufigste Arrhythmie und betrifft vermutlich mehr
prevalence of AF [15, 24, 25]. In contrast to als 30 Mio. Menschen weltweit. Studien berichten, dass das linke Herzohr („left
percutaneous LAAO trials, there are still no atrial appendage“ [LAA]) eine wichtige Rolle bei der Thrombusbildung spielt
randomized studies available comparing und als Emboliequelle bei 90 % der Patienten mit nichtvalvulärem und 57 % der
surgical closure with oral anticoagulation Patienten mit valvulärem Vorhofflimmern gilt. Orale Antikoagulanzien sind seit
Jahrzehnten der Behandlungsstandard zur Schlaganfallprävention bei Patienten mit
for stroke prevention. Previous experi-
Vorhofflimmern. Blutungskomplikationen und Noncompliance sind jedoch Hindernisse
ence suggests that traditional surgical
für einen wirksamen Schutz vor Embolien. Als Alternative zur konventionellen
exclusion techniques are ineffective due
antithrombotischen Therapie erfährt daher der chirurgische LAA-Verschluss
to recanalization of the LAA. zunehmende Aufmerksamkeit; dieser kann ebenfalls das Thromboembolierisiko
In order for surgical LAAO to be used verringern. Allerdings birgt das Verfahren auch Risiken wie eine verlängerte
routinely, it must demonstrate at least Operationszeit, eine Beschädigung des Ramus circumflexus und einen unvollständigen
comparable mortality rates when com- LAA-Verschluss. In dieser Übersicht diskutieren wir einige der Beobachtungsstudien,
pared with cardiac surgery without LAAO. die die Auswirkungen des LAA-Verschlusses auf Schlaganfälle untersuchten, und die
The clinical effect of LAAO on operative LAAOS-III-Studie (Left Atrial Appendage Occlusion Study), die endgültige Beweise für
time and effectiveness of various types den Nutzen des chirurgischen LAA-Verschlusses in Bezug auf ischämische Schlaganfälle
of surgical techniques for successful LAAO lieferte. Wir erörtern, welche Methoden zum Verschluss des LAA sicher und wirksam
have not been well evaluated. A standard- sind und ob die orale Antikoagulation nach der chirurgischen Entfernung des LAA
ized surgical technique for LAA closure is beendet werden kann.
not established yet.
Large scale, multicenter, prospective Schlüsselwörter
Vorhofflimmern · Linkes Herzohr · Verschluss · Herzchirurgie · Antikoagulation
randomized surgical trials with clear sur-
gical and anticoagulation protocols and
adequate long-term follow-up are needed
to provide strong evidence and validate 2. Zheng Y, Rao CF, Chen SP et al (2020) Surgical 10. Gillinov AM, Pettersson G, Cosgrove DM III (2005)
left atrial appendage occlusion in patients Stapled excision of the left atrial appendage.
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Follow-up should include data on anti- heart valve replacement. Chin Med J (Engl) 11. Healey JS, Crystal E, Lamy A et al (2005) Left Atrial
coagulation regime, rhythm analysis, and 133(16):1891–1899 Appendage Occlusion Study (LAAOS): results of
3. Collado FMS, Lama von Buchwald CM, Ander- a randomized controlled pilot study of left atrial
LAA closure status. son CK, Madan N, Suradi HS, Huang HD, Jneid H, appendage occlusion during coronary bypass
Kavinsky CJ (2021) Left atrial appendage occlusion surgery in patients at risk for stroke. Am Heart J
for stroke prevention in nonvalvular atrial fibrilla- 150:288–293
Corresponding address
tion. J Am Heart Assoc 10(21):e22274. https://doi. 12. Whitlock RP, Vincent J, Blackall MH et al (2013) Left
Magdalena Rufa, MD org/10.1161/JAHA.121.022274 atrial appendage occlusion study II (LAAOS II). Can
Department of Cardiovascular Surgery, Robert 4. Whitlock RP, Belley-Cote EP, Paparella D et al J Cardiol 29:1443–1447
(2021) Left atrial appendage occlusion during 13. Garcia-Fernandez MA, Perez-David E, Quiles J et al
Bosch Hospital Stuttgart
cardiac surgery to prevent stroke. N Engl J Med (2003) Role of left atrial appendage obliteration
Auerbachstraße 110, 70376 Stuttgart, Germany 384(22):2081–2091. https://doi.org/10.1056/ in stroke reduction in patients with mitral valve
[email protected] NEJMoa2101897 prosthesis: a transesophageal echocardiographic
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nov AM, Bakaeen FG, Edgerton JR, Philpott JM, org/10.1016/S0735-1097(03)00954-9
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Declarations Suri RM, Shemin RJ, Firestone S, Ad N (2017) Surgical left atrial appendage occlusion during
The Society of Thoracic Surgeons 2017 clinical cardiac surgery for patients with atrial fibrillation: a
Conflict of interest. M. Rufa, N. Göbel, and practice guidelines for the surgical treatment of meta-analysis. Eur J Cardiothorac Surg 47:847–854
U. F. W. Franke declare that they have no conflicts of atrial fibrillation. Ann Thorac Surg 103(1):329–341. 15. Friedman DJ, Piccini JP, Wang T et al (2018) Asso-
interest. https://doi.org/10.1016/j.athoracsur.2016.10.076 ciation between left atrial appendage occlusion
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This article does not contain any studies with human atrial appendage: structure, function, and role in patients with atrial fibrillation undergoing con-
participants or animal subjects performed by any of thromboembolism. Heart 82:547–554. https:// comitant cardiac surgery. JAMA 319(4):365–374.
the authors. doi.org/10.1136/hrt.82.5.547 https://doi.org/10.1001/jama.2017.20125
7. Bakhtiary F, Kleine P, Martens S et al (2008) 16. Atti V, Anantha-Narayanan M, Turagam MK et al
Simplified technique forsurgical ligation of the left (2018) Surgical left atrial appendage occlusion
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