December 1, 2005

Short Movie: Left Atrial Ligation using the PDS Endoloop (1.7 MB Quicktime)

Reports in the medical literature indicate that 95% of left atrial thrombi identified by transesophageal echo in patients with atrial fibrillation (AF) are located within the left atrial appendage [Sievert 2002]. The incidence of AF following CABG is between 15% and 30%. Embolic strokes with postoperative AF are uncommon, but there is increasing evidence that AF is a true risk factor for postoperative stroke. However, routine anticoagulation with warfarin to prevent stroke from postoperative AF is also associated with unwanted bleeding complications such a hemothorax, hemorrhagic pericardial effusions/tamponade, and gastrointestinal bleeding.

It make sense that routine closure of the LA appendage will reduce or eliminate the need for warfarin. In the past, surgeons have been cautious about closing the LA appendage because the tissue is more fragile and prone to unwanted tearing and bleeding than the right atrial appendage.

Recently, I have been performing routine surgical ligation of the left atrial appendage using two Endoloops during all open heart cases, including CABG. If the patient develops postoperative AF, I have not used warfarin unless there is another separate indication (such as a mechanical valve).

The Endoloop is quick and easy. PDS Endoloops slide easier than Vicryl Endoloops. Since the suture is thick, tearing is not likely. This procedure is suitable for on-pump, off-pump or lateral thoracotomy cases.

Mark M. Levinson, MD
Chief, Cardiothoracic Surgery
Hutchinson Hospital
Hutchinson, KS USA

1. Sievert H, Lesh MD, Trepels T, et. al. Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation. Early clinical experience. Circulation 2002; 105:1887-1889.