Case Reports
Thromboembolus from a ligated left atrial appendage*

https://doi.org/10.1067/mje.2001.110328Get rights and content

Abstract

The left atrial appendage of patients with mitral valve disease is commonly a source of thromboembolus and is often ligated during mitral valve surgery to diminish this risk. However, ligation is often incomplete. We describe a patient with a stroke whose only source of embolus was an incompletely ligated left atrial appendage. Attempts to exclude the left atrial appendage from the arterial circulation by suture ligation may not decrease the risk of thromboemboli and instead may increase such risk. (J Am Soc Echocardiogr 2001;14:396-8.)

Section snippets

Case report

A 69-year-old man was referred for echocardiographic evaluation after a recent cerebrovascular accident. Four years earlier, he had undergone a ring annuloplasty mitral valve repair for a flail posterior leaflet and severe mitral regurgitation associated with congestive heart failure. The left atrial appendage was ligated with endocardial suturing. An intraoperative transesophageal echocardiogram demonstrated no aortic atherosclerosis.

Two weeks before the above evaluation, the patient had a

Discussion

Ligation of the left atrial appendage is effected during mitral valve surgery to exclude it from the circulation and to eliminate it as a potential source of systemic emboli. Randomized studies demonstrating the benefit of this undertaking have never been reported. Although complete obliteration of the appendage is the surgical intent, our laboratory and others have used intraoperative transesophageal echocardiography to demonstrate residual communication between the left atrium and its

Conclusion

Although it seems intuitively desirable to exclude a potentially stagnant pool of blood from the systemic circulation by endocardial suture ligation of the left atrial appendage, the prospect of often leaving a persistent communication between a thrombosed appendage and the body of the left atrium makes this a questionable undertaking. Endocardial ligation of the left atrial appendage may not reduce the risk of thromboembolism—in some cases, in fact, it may increase such risk.

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  • The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture)

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    Endocardial suture ligation of the LAA is an extremely invasive procedure requiring the use of cardiopulmonary bypass and invasion of the atrial dome with associated risk of bleeding and injury to the circumflex coronary artery owing to its proximity to the LAA. In addition, endocardial suture ligation has been shown to be incomplete in 10% to 30% of patients.32–34 This high rate of incomplete closure is attributed to several factors: the procedure is performed when the heart is in a flaccid state, the access is generally awkward for traditional suturing, and there is no ready method to confirm completeness of closure intraoperatively.

  • Percutaneous left atrial appendage suture ligation using the lariat device in patients with atrial fibrillation: Initial clinical experience

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    Exclusion of the LAA with epicardial suture ligation or surgical staplers is possible without cardiopulmonary bypass (34). However, epicardial suture closure ranges from 23% to 100% (20,30–32,35–37), whereas reported LAA closure rates using surgical staplers range from 0% to 80% (20,35). Procedural and anatomical variables leading to incomplete epicardial suture ligation include operator variability with suture tightening, the presence of prosthetic mitral valves or annuloplasty rings, and the complex anatomy of the LAA ostium (38).

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Reprint requests: Itzhak Kronzon, MD, 560 First Avenue, HW 228, New York, NY 10016 (E-mail: [email protected]).

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