Katz E S, Tsiamtsiouris T, Applebaum R M, Schwartzbard A, Tunick P A, Kronzon I
Department of Medicine, New York University School of Medicine, New York, USA.
J Am Coll Cardiol. 2000 Aug;36(2):468-71. doi: 10.1016/s0735-1097(00)00765-8.
This study sought to determine the incidence of incomplete ligation of the left atrial appendage (LAA) during mitral valve surgery.
Ligation of the LAA to prevent future thromboembolic events is commonly performed during mitral surgery. However, success in completely excluding the appendage from the circulation has never been systematically assessed.
Using transesophageal Doppler echocardiography, we studied 50 patients who underwent mitral valve surgery and ligation of the LAA. Thirty patients were studied immediately postoperative, and 20 patients were studied 6 days to 13 years after surgery. Incomplete ligation was detected by demonstrating a color jet traversing the separation between the left atrial body and appendage.
Transesophageal echocardiography detected incomplete LAA ligation in 18 of 50 (36%) patients. The incidence of incomplete ligation was not significantly different between patients studied immediately postoperative and patients studied at various times after surgery. Type of mitral surgery (repair vs. replacement), operative approach (sternotomy vs. port access), left atrial size or degree of mitral regurgitation did not significantly correlate with the incidence of incomplete appendage ligation. However, the power to detect a significant difference in left atrial size was only 64%. Spontaneous echo contrast or thrombus was identified within appendages in 9 of 18 (50%) patients with incomplete ligation, while 4 of these 18 (22%) patients had thromboembolic events.
Surgical LAA ligation is frequently incomplete. The similar incidence of incomplete ligation detected immediately postoperative and at various times thereafter suggest that this results from an intraoperative phenomenon rather than from gradual dehiscence of sutures over years. The incidence of incomplete left atrial ligation was unrelated to type of surgery, surgical approach, left atrial size or degree of mitral regurgitation. Residual communication between the incompletely ligated appendage and the left atrial body may produce a milieu of stagnant blood flow within the appendage and be a potential mechanism for embolic events.
本研究旨在确定二尖瓣手术期间左心耳（LAA）结扎不完全的发生率。
二尖瓣手术期间通常会结扎LAA以预防未来的血栓栓塞事件。然而，从未对将心耳完全排除在循环之外的成功率进行过系统评估。
我们使用经食管多普勒超声心动图研究了50例行二尖瓣手术并结扎LAA的患者。30例患者在术后立即进行研究，20例患者在术后6天至13年进行研究。通过显示彩色血流束穿过左心房主体与心耳之间的分隔来检测结扎不完全。
经食管超声心动图在50例患者中的18例（36%）检测到LAA结扎不完全。术后立即研究的患者与术后不同时间研究的患者之间，结扎不完全的发生率无显著差异。二尖瓣手术类型（修复术与置换术）、手术入路（胸骨切开术与端口入路）、左心房大小或二尖瓣反流程度与心耳结扎不完全的发生率无显著相关性。然而，检测左心房大小显著差异的效能仅为64%。18例结扎不完全的患者中有9例（50%）在心耳内发现自发显影或血栓，而这18例患者中有4例（22%）发生了血栓栓塞事件。
手术结扎LAA常常不完全。术后立即及之后不同时间检测到的结扎不完全发生率相似，这表明这是一种术中现象，而非多年来缝线逐渐裂开所致。左心房结扎不完全的发生率与手术类型、手术入路、左心房大小或二尖瓣反流程度无关。不完全结扎的心耳与左心房主体之间的残余交通可能会在心房内产生血流淤滞的环境，并且是栓塞事件的潜在机制。
