Left Atrial Appendage Patency at Cardioversion After Surgical Left Atrial Appendage Intervention

Michael W. Cullen, John M. Stulak, Zhuo Li, Brian D. Powell, Roger D. White, Naser M. Ammash, Vuyisile T Nkomo

Research output: Contribution to journalArticle

18 Citations (Scopus)

Abstract

Background Surgical left atrial appendage (LAA) closure is often incomplete, with patients frequently requiring direct current cardioversion (DCCV) for atrial arrhythmias. Transesophageal echocardiography (TEE) is often performed before DCCV to exclude LAA thrombus. The impact of incomplete surgical LAA closure on patients referred for postoperative DCCV is unknown. Methods We retrospectively reviewed patients undergoing TEE-guided DCCV within 30 days of cardiac surgery and surgical LAA closure. All pre-DCCV TEEs were reviewed to assess LAA patency and the presence of thrombus. Results Ninety-three patients (mean age 68 years; 61 men [66%]) had a median time from surgery to DCCV of 6 days. Duration of atrial fibrillation was 48 hours or more in 85% (n = 79). On pre-DCCV TEE, a residual communication from the LAA was noted in 37% (n = 34). The rate of LAA patency was higher after suture closure than after surgical excision or staple closure. Thrombus was present in 26 of the 93 patients (28%), including 16 of 34 patients (47%) with incomplete closure of LAA. The strongest risk factor for thrombus was a patent, partially closed LAA (odds ratio 4.36, p = 0.003). Systemically accessible thrombus was present in 19 of the 93 patients (20%), and cardioversion was cancelled owing to thrombus in 15 (16%). Conclusions Surgical closure of the LAA is often incomplete. Interrogation of the residual LAA after surgical LAA intervention with TEE before DCCV frequently detects thrombus and alters clinical management. Patients undergoing DCCV after surgical LAA intervention require evaluation with TEE for LAA patency and thrombus.

Original languageEnglish (US)
Pages (from-to)675-681
Number of pages7
JournalAnnals of Thoracic Surgery
Volume101
Issue number2
DOIs
StatePublished - Feb 1 2016

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Atrial Appendage
Electric Countershock
Thrombosis
Transesophageal Echocardiography
Ambulatory Surgical Procedures
Atrial Fibrillation
Sutures
Thoracic Surgery

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine
  • Medicine(all)

Cite this

Left Atrial Appendage Patency at Cardioversion After Surgical Left Atrial Appendage Intervention. / Cullen, Michael W.; Stulak, John M.; Li, Zhuo; Powell, Brian D.; White, Roger D.; Ammash, Naser M.; Nkomo, Vuyisile T.

In: Annals of Thoracic Surgery, Vol. 101, No. 2, 01.02.2016, p. 675-681.

Research output: Contribution to journalArticle

Cullen, Michael W. ; Stulak, John M. ; Li, Zhuo ; Powell, Brian D. ; White, Roger D. ; Ammash, Naser M. ; Nkomo, Vuyisile T. / Left Atrial Appendage Patency at Cardioversion After Surgical Left Atrial Appendage Intervention. In: Annals of Thoracic Surgery. 2016 ; Vol. 101, No. 2. pp. 675-681.
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abstract = "Background Surgical left atrial appendage (LAA) closure is often incomplete, with patients frequently requiring direct current cardioversion (DCCV) for atrial arrhythmias. Transesophageal echocardiography (TEE) is often performed before DCCV to exclude LAA thrombus. The impact of incomplete surgical LAA closure on patients referred for postoperative DCCV is unknown. Methods We retrospectively reviewed patients undergoing TEE-guided DCCV within 30 days of cardiac surgery and surgical LAA closure. All pre-DCCV TEEs were reviewed to assess LAA patency and the presence of thrombus. Results Ninety-three patients (mean age 68 years; 61 men [66{\%}]) had a median time from surgery to DCCV of 6 days. Duration of atrial fibrillation was 48 hours or more in 85{\%} (n = 79). On pre-DCCV TEE, a residual communication from the LAA was noted in 37{\%} (n = 34). The rate of LAA patency was higher after suture closure than after surgical excision or staple closure. Thrombus was present in 26 of the 93 patients (28{\%}), including 16 of 34 patients (47{\%}) with incomplete closure of LAA. The strongest risk factor for thrombus was a patent, partially closed LAA (odds ratio 4.36, p = 0.003). Systemically accessible thrombus was present in 19 of the 93 patients (20{\%}), and cardioversion was cancelled owing to thrombus in 15 (16{\%}). Conclusions Surgical closure of the LAA is often incomplete. Interrogation of the residual LAA after surgical LAA intervention with TEE before DCCV frequently detects thrombus and alters clinical management. Patients undergoing DCCV after surgical LAA intervention require evaluation with TEE for LAA patency and thrombus.",
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N2 - Background Surgical left atrial appendage (LAA) closure is often incomplete, with patients frequently requiring direct current cardioversion (DCCV) for atrial arrhythmias. Transesophageal echocardiography (TEE) is often performed before DCCV to exclude LAA thrombus. The impact of incomplete surgical LAA closure on patients referred for postoperative DCCV is unknown. Methods We retrospectively reviewed patients undergoing TEE-guided DCCV within 30 days of cardiac surgery and surgical LAA closure. All pre-DCCV TEEs were reviewed to assess LAA patency and the presence of thrombus. Results Ninety-three patients (mean age 68 years; 61 men [66%]) had a median time from surgery to DCCV of 6 days. Duration of atrial fibrillation was 48 hours or more in 85% (n = 79). On pre-DCCV TEE, a residual communication from the LAA was noted in 37% (n = 34). The rate of LAA patency was higher after suture closure than after surgical excision or staple closure. Thrombus was present in 26 of the 93 patients (28%), including 16 of 34 patients (47%) with incomplete closure of LAA. The strongest risk factor for thrombus was a patent, partially closed LAA (odds ratio 4.36, p = 0.003). Systemically accessible thrombus was present in 19 of the 93 patients (20%), and cardioversion was cancelled owing to thrombus in 15 (16%). Conclusions Surgical closure of the LAA is often incomplete. Interrogation of the residual LAA after surgical LAA intervention with TEE before DCCV frequently detects thrombus and alters clinical management. Patients undergoing DCCV after surgical LAA intervention require evaluation with TEE for LAA patency and thrombus.

AB - Background Surgical left atrial appendage (LAA) closure is often incomplete, with patients frequently requiring direct current cardioversion (DCCV) for atrial arrhythmias. Transesophageal echocardiography (TEE) is often performed before DCCV to exclude LAA thrombus. The impact of incomplete surgical LAA closure on patients referred for postoperative DCCV is unknown. Methods We retrospectively reviewed patients undergoing TEE-guided DCCV within 30 days of cardiac surgery and surgical LAA closure. All pre-DCCV TEEs were reviewed to assess LAA patency and the presence of thrombus. Results Ninety-three patients (mean age 68 years; 61 men [66%]) had a median time from surgery to DCCV of 6 days. Duration of atrial fibrillation was 48 hours or more in 85% (n = 79). On pre-DCCV TEE, a residual communication from the LAA was noted in 37% (n = 34). The rate of LAA patency was higher after suture closure than after surgical excision or staple closure. Thrombus was present in 26 of the 93 patients (28%), including 16 of 34 patients (47%) with incomplete closure of LAA. The strongest risk factor for thrombus was a patent, partially closed LAA (odds ratio 4.36, p = 0.003). Systemically accessible thrombus was present in 19 of the 93 patients (20%), and cardioversion was cancelled owing to thrombus in 15 (16%). Conclusions Surgical closure of the LAA is often incomplete. Interrogation of the residual LAA after surgical LAA intervention with TEE before DCCV frequently detects thrombus and alters clinical management. Patients undergoing DCCV after surgical LAA intervention require evaluation with TEE for LAA patency and thrombus.

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