The left atrial appendage: our most lethal human attachment! Surgical implications

Objectives: To prevent death from atrial fibrillation, a cardiac disease wh ich kills by producing emboli. Atrial fibrillation causes about 25% of stro kes and increases stroke rate by five times. Over 90% of these embolic stro kes are from clots originating in the left atrial appendage. This study add resses the surgical feasibility of removing the appendage to prevent future deaths in two subcategories of patients. (1) Prophylactic removal during o pen-heart surgery to study its safety. Theoretically, as these patients age and some develop atrial fibrillation, protection from embolic strokes woul d already be present. (2) Therapeutic removal in chronic atrial fibrillatio n patients by means of a thorascopic approach. Its technical feasibility is demonstrated. Its actual stroke prevention potential awaits large studies. Methods: Appendectomy has been evaluated three ways. (1) Experimentally, t horascopic appendage removal was performed on 20 goats with endoscopic appr oach. Late studies showed a cleanly healed atrial closure after stapling, a nd no puckering of tissue as seen with the purse-string approach. (2) Safet y of human appendectomy was demonstrated in 437 patients (1995-1997). Routi ne appendectomy was performed during open-heart surgery. Forty-three append ages were stapled, 391 sutured off. (3) Thorascopic appendectomy in seven p atients with chronic atrial fibrillation has been successfully accomplished as an isolated surgical procedure. Stapling or suture closure provides a m uch cleaner, non-puckered suture line than a purse string. Results: In prop hylactic removal, no acute bleeding occurred. No late problems have been id entified. Endoscopic removal of the appendage has been successful in seven atrial fibrillation patients. Conclusions: The left atrial appendage is a l ethal source of emboli in atrial fibrillation patients. As patients age and often develop atrial fibrillation, prophylactic appendage removal whenever the chest is open is suggested as a method to prevent future strokes. In c hronic atrial fibrillation patients, appendectomy can be done with a mini-t horascopic approach. Further studies are planned to demonstrate the effecti veness of appendectomy in preventing strokes in the chronic fibrillating pa tients. (C) 2000 Elsevier Science B.V. All rights reserved.