Department of Cardiothoracic Surgery, Cairo University, Cairo, Egypt.
Madinah Cardiac Center, Minia University, Minia, King Fahd Hospital, KSA, Egypt.
Heart Surg Forum. 2021 Oct 21;24(5):E901-E905. doi: 10.1532/hsf.3511.
To find out the most successful surgical technique to obliterate left atrial appendage (LAA) in atrial fibrillation (AF) patients who had undergone concomitant cardiac surgery.
About 10%-65% of patients develop AF following cardiac surgery [Rho 2009; Mathew 2004; Maesen 2012]. Cerebral cardio-embolic stroke remains the most serious complication in AF patients. LAA is the main anatomical source for thromboembolic events. The use of oral anticoagulants (OAG) is considered to be an effective method for reduction of thromboembolic complications [Johnson 2000]. The use of oral anticoagulants is faced by two important facts which are the therapy duration is still unknown [Kirchhof 2017] and importantly that between 30-50% of patients are not candidates for oral anticoagulants due to the high bleeding risk or other contraindications [Johnson 2000; Kirchhof 2017; Kirchhof 2014]. In such patients, LAA obliteration would be an optimal alternative technique as it will reduce the stroke risk by 50% [Go 2014]. Several surgical techniques with variable degrees of success rates have been used. It still is unclear which surgical technique is optimum to achieve a successful obliteration of the LAA and a considerable reduction of the postoperative stroke events in AF patients.
A total of 100 patients have been subjected to surgical LAA exclusion from April 2017 to April 2019 in two different centers. All patients had postoperative transesophageal echo (TEE) examination to confirm the success of LAA occlusion. All patients included in our study suffered from AF at the time of surgery or in past history, which was confirmed by ECG examination in their previous medical files. A variety of surgical techniques to close the LAA have been utilized, including surgical excision by means of scissors, patch exclusion by means of an endocardial patch, suture exclusion and finally stapler exclusion. TEE examination 16 months postoperatively divided our patients into four groups as follows: successful LAA occlusion, Patent LAA, excluded LAA with persistent flow into LAA, and remnant LAA with a stump connection with LAA more than 1 cm.
Out of 100 patients, 30 patients (30%) underwent surgical LAA excision, 24 patients (24%) underwent surgical epicardial suture ligation, eight patients (8%) underwent patch exclusion using autologous pericardial patch, 33 patients (33%) underwent LAA internal orifice purse string suture obliteration, and five patients (5%) underwent stapler exclusion. Forty-two patients out of 100 (42%) showed successful LAA closure. The successful LAA occlusion occurred mostly in LAA excision patients 87%, 24% in LAA internal orifice purse string suture obliteration patients, 21% in epicardial suture ligation patients, and 37.5% in patch exclusion patients. The stapler exclusion was very disappointing as we did not record a single case out of the five patients who showed a successful LAA occlusion. Stroke events were recorded in all surgical techniques except the LAA excision technique. The stroke rate after two years follow up was zero in the surgical excision group, 49% in the suture exclusion group, 20% in the patch exclusion group, and 40% in stapler exclusion group.
Surgical LAA excision is the most successful technique for LAA occlusion and represents a promising technique for the reduction of thromboembolic events in AF patients who undergo a concomitant cardiac surgery.
找出在同时进行心脏手术的房颤（AF）患者中，使左心耳（LAA）闭塞最成功的手术技术。
约 10%-65%的心脏手术后患者会发生 AF [Rho 2009；Mathew 2004；Maesen 2012]。AF 患者仍然是脑心源性栓塞性中风最严重的并发症。LAA 是血栓栓塞事件的主要解剖源。口服抗凝剂（OAG）的使用被认为是减少血栓栓塞并发症的有效方法 [Johnson 2000]。使用口服抗凝剂面临两个重要事实，即治疗持续时间仍不清楚 [Kirchhof 2017]，重要的是，由于高出血风险或其他禁忌症，30-50%的患者不适合使用口服抗凝剂 [Johnson 2000；Kirchhof 2017；Kirchhof 2014]。在这些患者中，LAA 闭塞将是一种最佳的替代技术，因为它将使中风风险降低 50% [Go 2014]。已经使用了几种具有不同成功率的手术技术。哪种手术技术最适合实现 LAA 的成功闭塞，并在 AF 患者中显著减少术后中风事件，目前仍不清楚。
我们在两个不同的中心对 100 例患者进行了外科 LAA 排除手术，时间从 2017 年 4 月至 2019 年 4 月。所有患者均在术后进行经食管超声心动图（TEE）检查，以确认 LAA 闭塞成功。我们研究中的所有患者在手术时或既往病史中均患有 AF，这通过其既往病历中的心电图检查得到证实。我们使用了各种外科技术来关闭 LAA，包括通过剪刀进行外科切除、通过心内膜补片进行补丁排除、缝线排除和最后使用吻合器排除。术后 16 个月的 TEE 检查将我们的患者分为四组：LAA 闭塞成功、LAA 未闭、LAA 仍有持续血流、LAA 残端与 LAA 连接 1 厘米以上。
100 例患者中，30 例（30%）行外科 LAA 切除术，24 例（24%）行外科心外膜缝线结扎术，8 例（8%）行自体心包补丁排除术，33 例（33%）行 LAA 内口荷包缝线闭塞术，5 例（5%）行吻合器排除术。100 例患者中有 42 例（42%）显示 LAA 关闭成功。LAA 闭塞最常见于 LAA 切除术患者（87%），其次是 LAA 内口荷包缝线闭塞患者（24%）、心外膜缝线结扎患者（21%）和补丁排除患者（37.5%）。吻合器排除术令人非常失望，因为我们在五例患者中没有一例显示 LAA 闭塞成功。除 LAA 切除术外，所有手术技术均记录到中风事件。在两年的随访后，外科切除组的中风发生率为零，缝线结扎组为 49%，补丁排除组为 20%，吻合器排除组为 40%。
外科 LAA 切除术是 LAA 闭塞最成功的技术，代表了一种有前途的技术，可以减少同时进行心脏手术的 AF 患者的血栓栓塞事件。
