title: Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization.
abstract: BACKGROUND
  Surgical exclusion of the left atrial appendage (LAA) can frequently yield incomplete closure.
  
  
  OBJECTIVE
  We evaluated the ischemic stroke/systemic embolization (SSE) risk in patients with atrial fibrillation (AF) and complete LAA closure (cLAA) vs incompletely surgically ligated LAA (ISLL) and LAA stump after surgical suture ligation.
  
  
  METHODS
  Seventy-two patients (CHA2DS2-VASc score 4.1 ± 1.9) underwent surgical LAA ligation in conjunction with mitral valve/AF surgery and postoperative LAA evaluation using computerized tomographic angiography.
  
  
  RESULTS
  Overall, cLAA was detected in 46 of 72 patients (64%), ISLL in 17 patients (24%), and LAA stump in 9 patients (12%). The incidences of oral anticoagulation (OAC) and recurrent AF were similar among the 3 groups during 44 ± 19 months of follow-up. SSE occurred in 2% of patients with cLAA vs 24% with ISLL and 0% with LAA stump (P = .006). None of the patients with SSE were receiving OAC, and all had recurrent AF during follow-up. Additionally, patients with SSE exhibited a significantly smaller ISLL neck diameter (2.8 ± 1.0 vs 7.1 ± 2.1 mm; P = .002). The annualized SSE risk was 1.9% (entire cohort), 6.5% (ISLL patients), 14.4% (ISLL patients not receiving OAC), and 19.0% (ISLL neck diameter ≤5.0 mm) per 100 patient-years of follow-up. The latter risk was nearly 5 times greater than predicted by conventional risk-stratification schemes. Moreover, ISLL emerged as an independent predictor of SSE in univariate analyses and as the sole predictor of SSE in a multivariate analysis.
  
  
  CONCLUSIONS
  In patients with AF, ISLL is a predictor of SSE, independent of conventional risk stratification schemes. Consequently, OAC should be strongly considered in this high-risk cohort.
authors.affiliation: Regional Cardiology Associates, Sacramento, California; Dignity Health Heart and Vascular Institute, Sacramento, California. Electronic address: aaryana@rcamd.com.
authors.forename: Arash
authors.initials: A
authors.lastname: Aryana
authors.affiliation: Department of Cardiothoracic Surgery, CHI Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, Texas.
authors.forename: Steve K
authors.initials: SK
authors.lastname: Singh
authors.affiliation: Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Sheldon M
authors.initials: SM
authors.lastname: Singh
authors.affiliation: Regional Cardiology Associates, Sacramento, California; Dignity Health Heart and Vascular Institute, Sacramento, California.
authors.forename: P Gearoid
authors.initials: PG
authors.lastname: O'Neill
authors.affiliation: Regional Cardiology Associates, Sacramento, California; Dignity Health Heart and Vascular Institute, Sacramento, California.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Bowers
authors.affiliation: Regional Cardiology Associates, Sacramento, California.
authors.forename: Shelley L
authors.initials: SL
authors.lastname: Allen
authors.affiliation: Regional Cardiology Associates, Sacramento, California.
authors.forename: Sammi L
authors.initials: SL
authors.lastname: Lewandowski
authors.affiliation: Regional Cardiology Associates, Sacramento, California.
authors.forename: Eleanor C
authors.initials: EC
authors.lastname: Vierra
authors.affiliation: Instituto de Pesquisa em Arritmia Cardiaca, Hospital Cardiologico-Florianopolis, Florianopolis, Santa Catarina, Brazil.
authors.forename: André
authors.initials: A
authors.lastname: d'Avila
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020517:Atrial Appendage / Q000601:surgery*; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D001938:Brazil; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008026:Ligation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000517:prevention & control; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control; D013923:Thromboembolism / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control; D058106:Wound Closure Techniques / Q000009:adverse effects
keywords: Cardiac surgery; Incomplete closure; Left atrial appendage; Ligation; Stroke