title: Epicardial surgical ligation of the left atrial appendage is safe, reproducible, and effective by transesophageal echocardiographic follow-up.
abstract: OBJECTIVE
  The left atrial appendage (LAA) is the source of 90% of thrombi in patients with atrial fibrillation. Our double LAA ligation (LLAA) technique was shown to be 96% successful in a small study. However, the outcomes of these patients have yet to be compared with a set of nonligated patients.
  
  
  METHODS
  From 2005 to 2012, a total of 808 patients received LAA using our double ligation technique using both a polydioxanone (PDS) II endosnare and a running 4-0 Prolene pledgeted suture. The 30-day outcomes of these patients were compared with that of nonligated patients. Fifty-six of the ligated patients had a postoperative transesophageal echocardiography (TEE). An echocardiographer reviewed the follow-up TEEs for LAA remnant and/or residual flow into the LAA using color Doppler imaging. The patients with LAA flow and/or remnant depth of 1 cm or greater were deemed to have an unsuccessful exclusion.
  
  
  RESULTS
  The ligated group had a trend of less postoperative atrial fibrillation (19.4% vs 22.9%, P = 0.07) and an overall significantly lower in-hospital mortality (0.7% vs 3.0%, P < 0.001) and lower 30-day mortality (0.7% vs 3.4%, P < 0.0001). The LAA was successfully excluded in 53 (94.7%) of the 56 patients with TEE.
  
  
  CONCLUSIONS
  Double LAA ligation correlates with lower rates of in-hospital and 30-day mortality. This advantage comes without an increase in perioperative complications. This technique can easily be performed off or on pump, is very reproducible, and comes at a very low cost compared with LAA occlusion devices. Stroke has a multifactorial etiology; successful LLAA removes one potential source of thrombi perioperatively and in the long-term.
authors.affiliation: From *The Valley Columbia Heart Center, Columbia University College of Physicians and Surgeons, Ridgewood, NJ USA; and †The University of Pennsylvania School of Medicine, Glenolden, PA USA.
authors.forename: Alex
authors.initials: A
authors.lastname: Zapolanski
authors.forename: Christopher K
authors.initials: CK
authors.lastname: Johnson
authors.forename: Omid
authors.initials: O
authors.lastname: Dardashti
authors.forename: Ryan M
authors.initials: RM
authors.lastname: O'Keefe
authors.forename: Nancy
authors.initials: N
authors.lastname: Rioux
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ferrari
authors.forename: Richard E
authors.initials: RE
authors.lastname: Shaw
authors.forename: Mariano E
authors.initials: ME
authors.lastname: Brizzio
authors.forename: Juan B
authors.initials: JB
authors.lastname: Grau
mesh_terms: D000368:Aged; D020517:Atrial Appendage / Q000000981:diagnostic imaging / Q000601:surgery*; D001281:Atrial Fibrillation / Q000601:surgery; D017548:Echocardiography, Transesophageal / Q000379:methods; D005260:Female; D006801:Humans; D008026:Ligation / Q000379:methods; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000000981:diagnostic imaging / Q000601:surgery*; D013536:Suture Techniques / Q000295:instrumentation; D013537:Sutures; D016896:Treatment Outcome