title: Left Atrial Appendage Patency at Cardioversion After Surgical Left Atrial Appendage Intervention.
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.
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address: cullen.michael@mayo.edu.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Cullen
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
authors.forename: John M
authors.initials: JM
authors.lastname: Stulak
authors.affiliation: Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota.
authors.forename: Zhuo
authors.initials: Z
authors.lastname: Li
authors.affiliation: Sanger Heart and Vascular Institute, Carolinas Health Care System, Charlotte, North Carolina.
authors.forename: Brian D
authors.initials: BD
authors.lastname: Powell
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular and Thoracic Anesthesia, Mayo Clinic, Rochester, Minnesota.
authors.forename: Roger D
authors.initials: RD
authors.lastname: White
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Naser M
authors.initials: NM
authors.lastname: Ammash
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Vuyisile T
authors.initials: VT
authors.lastname: Nkomo
mesh_terms: D000368:Aged; D020517:Atrial Appendage / Q000601:surgery*; D001281:Atrial Fibrillation / Q000601:surgery*; D015331:Cohort Studies; D017548:Echocardiography, Transesophageal; D004554:Electric Countershock; D005260:Female; D006331:Heart Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology; D012189:Retrospective Studies; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000453:epidemiology