title: [Surgical closure of the left atrial appendage in patients with atrial fibrillation. Indications, techniques and results].
abstract: Cardiac embolisation in patients with atrial fibrillation accounts for the most serious complication of cerebral infarction. The left atrial appendage resembles the origin of these cardiac emboli in the majority of cases, although other anatomical areas of the left atrium might also be prerequisites for thrombus formation. Surgical closure of the left atrial appendage during an ablation therapy incorporates the theoretical possibility of reducing the rate of cardiac cerebral infarction. In order to achieve closure, different surgical strategies exist: either exclusion by over-sewing or snaring or excision by using scissors or a stapling device. All therapies incorporate pros and cons. One of the major complications and most feared side-effect is the recanalisation of a formerly closed left atrial appendage, especially in a thrombus filled left atrial appendage cavity. But also reopening of the formerly closed orificium and still existing remnants with communication to the left atrium might stand for an increased risk. Due to the good results of left atrial appendage excision, this surgical therapy at the moment presents the surgical gold standard, as this therapy is recommended in the updated ESC guidelines for the management of atrial fibrillation. If excision of the left atrial appendage will reduce the risk of cardiac embolisation needs to be examined in large prospective-randomized trials with a controlled systemic follow-up. So far, excision of the left atrial appendage as an alternative to oral anticoagulation, especially in patients with atrial fibrillation, is not recommended.
authors.affiliation: Klinik für Herz- und thorakale Gefäßchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany. thorsten.hanke@uksh.de
authors.forename: Thorsten
authors.initials: T
authors.lastname: Hanke
authors.forename: Hans-Hinrich
authors.initials: HH
authors.lastname: Sievers
authors.forename: Nicolas
authors.initials: N
authors.lastname: Doll
authors.forename: Timo
authors.initials: T
authors.lastname: Weimar
mesh_terms: D020517:Atrial Appendage / Q000601:surgery*; D001281:Atrial Fibrillation / Q000150:complications* / Q000601:surgery*; D013504:Cardiovascular Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D020766:Intracranial Embolism / Q000209:etiology / Q000517:prevention & control*; D018579:Patient Selection; D020521:Stroke / Q000209:etiology* / Q000517:prevention & control*; D016896:Treatment Outcome; D058106:Wound Closure Techniques
references.citation: Dtsch Med Wochenschr. 2004 Feb 13;129(7):299-304
references.pmid: 14765327
references.citation: Eur J Cardiothorac Surg. 2008 Oct;34(4):766-70
references.pmid: 18693117
references.citation: Lancet. 2009 Jan 10;373(9658):155-66
references.pmid: 19135613
references.citation: Int J Cardiol. 2012 Dec 15;162(1):e16-7
references.pmid: 22608275
references.citation: Ann Thorac Surg. 2010 Jul;90(1):e11-3
references.pmid: 20609733
references.citation: N Engl J Med. 2001 May 10;344(19):1411-20
references.pmid: 11346805
references.citation: Eur Heart J. 2012 Nov;33(21):2719-47
references.pmid: 22922413
references.citation: J Thorac Cardiovasc Surg. 2011 Nov;142(5):1002-9, 1009.e1
references.pmid: 21906756
references.citation: J Thorac Cardiovasc Surg. 2003 Dec;126(6):1822-8
references.pmid: 14688693
references.citation: Eur J Cardiothorac Surg. 2012 Jan;41(1):134-6
references.pmid: 21684756
references.citation: Ann Thorac Surg. 2012 Jun;93(6):2035-8; discussion 2038-40
references.pmid: 22632497
references.citation: Eur J Cardiothorac Surg. 2012 Jan;41(1):136-7
references.pmid: 22219498
references.citation: JACC Cardiovasc Imaging. 2010 Dec;3(12):1276-83
references.pmid: 21163457
references.citation: Stroke. 1991 Aug;22(8):983-8
references.pmid: 1866765
references.citation: J Cardiovasc Electrophysiol. 2004 Feb;15(2):250-62
references.pmid: 15028063
references.citation: Cardiology. 2005;104(3):127-32
references.pmid: 16118490
references.citation: Ann Thorac Surg. 2012 Dec;94(6):1886-92
references.pmid: 22959565
references.citation: JACC Cardiovasc Interv. 2010 Jan;3(1):98-104
references.pmid: 20129577
references.citation: Ann Thorac Surg. 2011 Dec;92(6):2283-92
references.pmid: 22029943
references.citation: J Am Coll Cardiol. 2008 Sep 9;52(11):924-9
references.pmid: 18772063