Cited by 1,686Atrial Fibrillation Management and OutcomesCardiac tumors and thrombiCardiovascular and Diving-Related Complications

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Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation

Blackshear, Joseph L., Odell, John A.·1996·The Annals of Thoracic Surgery

DOI 10.1016/0003-4975(95)00887-x

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Abstract

Background Left atrial appendage obliteration was historically ineffective for the prevention of postoperative stroke in patients with rheumatic atrial fibrillation who underwent operative mitral valvotomy. It is, however, a routine part of modern "curative" operations for nonrheumatic atrial fibrillation, such as the maze and corridor procedures.Methods To assess the potential of left atrial appendage obliteration to prevent stroke in nonrheumatic atrial fibrillation patients, we reviewed previous reports that identified the etiology of atrial fibrillation and evaluated the presence and location of left atrial thrombus by transesophageal echocardiography, autopsy, or operation.Results Twenty-three separate studies were reviewed, and 446 of 3,504 (13%) rheumatic atrial fibrillation patients, and 222 of 1,288 (17%) nonrheumatic atrial fibrillation patients had a documented left atrial thrombus. Anticoagulation status was variable and not controlled for. Thrombi were localized to, or were present in the left atrial appendage and extended into the left atrial cavity in 254 of 446 (57%) of patients with rheumatic atrial fibrillation. In contrast, 201 of 222 (91%) of nonrheumatic atrial fibrillation-related left atrial thrombi were isolated to, or originated in the left atrial appendage (p < 0.0001).Conclusions These data suggest that left atrial appendage obliteration is a strategy of potential value for stroke prophylaxis in nonrheumatic atrial fibrillation.

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Background
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Background
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Influential
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Background
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Background
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Background
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Background
Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery
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“Percutaneous left atrial appendage occlusion (LAAO) has emerged as a potential alternative to life-long oral anticoagulation because 90% or more of thrombi during AF are located in the left atrial appendage, a remnant of the primordial left atrium [121].”
Background
Impact of left atrial appendage location on risk of thrombus formation in patients with atrial fibrillation
Fang, R., Li, Y., Zhang, Y., Chen, Q., Liu, Q., & Li, Z. (2021) · Biomechanics and Modeling in Mechanobiology · doi:10.1007/s10237-021-01454-4 · Cited by 42
Transcatheter closure of the left atrial appendage: Initial experience with the amplatzer cardiac plug device
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Background
Left atrial appendage occlusion in octogenarians
Gafoor, S. A., Franke, J., Bertog, S. C., Boehm, P., Heuer, L., Gonzaga, M., Bauer, J., Braut, A., Lam, S., Vaškelytė, L., et al. (2013) · Catheterization and Cardiovascular Interventions · doi:10.1002/ccd.25297 · Cited by 40
“The vast majority of thrombi in patients with AF not associated with rheumatic valve disease originate in the LAA [11].”
Background
Twelve-month follow-up of left atrial appendage occlusion with Amplatzer Amulet
Kleinecke, C., Park, J., Goedde, M. F., Zintl, K., Schnupp, S., & Brachmann, J. (2017) · Cardiology Journal · doi:10.5603/cj.a2017.0017 · Cited by 40
Treatment of atrial fibrillation: a comprehensive review and practice guide
Li, J., Gao, M., Zhang, M., Liu, D., Li, Z., Du, J., & Hou, Y. (2020) · Cardiovascular journal of South Africa/Cardiovascular journal of Southern Africa · doi:10.5830/cvja-2019-064 · Cited by 42
Left atrial 4D flow cardiovascular magnetic resonance: a reproducibility study in sinus rhythm and atrial fibrillation
Spartera, M., Pessoa-Amorim, G., Stracquadanio, A., Ende, A. V., Fletcher, A. M., Manley, P., Neubauer, S., Ferreira, V. M., Casadei, B., Hess, A. T., et al. (2021) · Journal of Cardiovascular Magnetic Resonance · doi:10.1186/s12968-021-00729-0 · Cited by 40
“Pooled evidence from echocardiography, autopsies, and surgical inspection of the LA reveals that intracardiac thrombus formation generally occurs within the left atrial appendage (LAA), particularly in non-rheumatic heart disease [6, 7].”
Background
Left atrial reduction for chronic atrial fibrillation associated with mitral valve disease
Sankar, N. M., & Farnsworth, A. E. (1998) · The Annals of Thoracic Surgery · doi:10.1016/s0003-4975(98)00281-1 · Cited by 40
Mechanical antithrombotic intervention by LAA occlusion in atrial fibrillation
Yu, C., Khattab, A. A., Bertog, S. C., Lee, A. P., Kwong, J. S., Sievert, H., & Meier, B. (2013) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2013.158 · Cited by 39
EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion.
Meier, B., Blaauw, Y., Khattab, A., Lewalter, T., Sievert, H., Tondo, C., & Glikson, M. (2015) · PubMed · doi:10.4244/eijy14m08_18 · Cited by 39
Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease: systematic review and meta-analysis
Caldeira, D., David, C., Costa, J. N., Ferreira, J. J., & Pinto, F. J. (2017) · European Heart Journal - Cardiovascular Pharmacotherapy · doi:10.1093/ehjcvp/pvx028 · Cited by 39
“the left atrial appendage, VHD patients, particularly those with rheumatic VHD, thrombi are deemed to be formed outside from the left atrial appendage in 40% of the cases.(11) Therefore, it is not clear whether NOACs behave similarly in VHD patients.”
Background
Updates on Prevention of Cardioembolic Strokes
Topçuoğlu, M. A., Liu, L., Kim, D., & Gurol, M. E. (2018) · Journal of Stroke · doi:10.5853/jos.2018.00780 · Cited by 40
“LAA is known to be the site of thrombus in over 90% of NVAF patients with an embolic event.(32) The complex morphological features of the LAA are a possible explanation for this.”
Background
Preventing stroke in patients with atrial fibrillation: Current treatments and new concepts
Connolly, S. J. (2003) · American Heart Journal · doi:10.1067/mhj.2003.84 · Cited by 39
5-Year Results From the AMPLATZER Amulet Left Atrial Appendage Occluder Randomized Controlled Trial
Lakkireddy, D., Ellis, C. R., Thaler, D. E., Swarup, V., Gambhir, A., Hermiller, J. B., Nielsen‐Kudsk, J. E., Worthley, S. G., Nair, D. G., Schmidt, B., et al. (2024) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2024.10.101 · Cited by 38
ANMCO/AIAC/SICI-GISE/SIC/SICCH Consensus Document: percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation patients: indications, patient selection, staff skills, organisation, and training
Casu, G., Gulizia, M. M., Molon, G., Mazzone, P., Audo, A., Casolo, G., Lorenzo, E. D., Portoghese, M., Pristipino, C., Ricci, R. P., et al. (2017) · European Heart Journal Supplements · doi:10.1093/eurheartj/sux008 · Cited by 40
“In fact, in spite of the plentiful, universally accepted evidence of the benefits of OAT in reducing the risk of ischaemic stroke, many studies have revealed that this therapy is underused, especially in high-risk patients.(8,9) A large number of stroke risk layeringmethods have been produced on the basis of risk fact…”
Background
SCAI/ACC/HRS Institutional and Operator Requirements for Left Atrial Appendage Occlusion
Kavinsky, C. J., Kusumoto, F. M., Bavry, A. A., Bailey, S. R., Ellenbogen, K. A., Hess, P. L., Lustgarten, D. L., Moussa, I. D., & Spies, C. (2015) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2015.12.001 · Cited by 37
Over 1-year efficacy and safety of left atrial appendage occlusion versus novel oral anticoagulants for stroke prevention in atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials and observational studies
Li, X., Wen, S., Li, S., Bai, R., Liu, N., Feng, L., Ruan, Y., Du, X., Dong, J., & Ma, C. (2015) · Heart Rhythm · doi:10.1016/j.hrthm.2015.12.037 · Cited by 37
“strategy for stroke prevention in AF is exclusion of left atrial appendage (LAA) from systemic circulation, as 91% of thrombi in nonvalvular AF are formed in the LAA.(2) For patients with AF who are elderly, have a bleeding history, and/or are noncompliant, left atrial appendage occlusion (LAAO) may be a better stroke…”
Background
A Review Of The Relevant Embryology, Pathohistology, And Anatomy Of The Left Atrial Appendage For The Invasive Cardiac Electrophysiologist.
DeSimone, C. V., Prakriti, B. G., Tri, J. A., Syed, F. F., Noheria, A., & Asirvatham, S. J. (2015) · PubMed Central · doi:10.4022/jafib.1129 · Cited by 37
Nonpharmacological Management of Atrial Fibrillation in Patients at High Intracranial Hemorrhage Risk
Gurol, M. E. (2017) · Stroke · doi:10.1161/strokeaha.117.017081 · Cited by 36
Percutaneous left atrial appendage closure versus non-vitamin K oral anticoagulants in patients with non-valvular atrial fibrillation and high bleeding risk
Godino, C., Melillo, F., Bellini, B., Mazzucca, M., Pivato, C. A., Rubino, F., Figini, F., Mazzone, P., Bella, P. E. D., Margonato, A., et al. (2020) · EuroIntervention · doi:10.4244/eij-d-19-00507 · Cited by 37
Geriatric Cardiac Surgery: Chronology vs. Biology
Seco, M., Edelman, J. J., Forrest, P., Ng, M. K. C., Wilson, M. K., Fraser, J. F., Bannon, P. G., & Vallely, M. P. (2014) · Heart Lung and Circulation · doi:10.1016/j.hlc.2014.04.008 · Cited by 37
Surgery for atrial fibrillation
Lee, R., Kruse, J. T., & McCarthy, P. M. (2009) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2009.106 · Cited by 36
“A growing body of indirect evidence suggests that the left atrial appendage might be the site of thrombus in as many as 90% of AF stroke patients without rheumatic disease”
Background
Left Atrial Appendage Volume Increased in More Than Half of Patients with Cryptogenic Stroke
Taina, M., Vanninen, R. L., Hedman, M., Jäkälä, P., Kärkkäinen, S., Tapiola, T., & Sipola, P. (2013) · PLoS ONE · doi:10.1371/journal.pone.0079519 · Cited by 38
“It has previously been suggested that measurement of LAA volume could theoretically be valuable for detecting risk patients, because cardioembolic stroke/TIA is a common source of ischemic stroke/TIA, and over 90% of detected LA thrombi are found within the LAA [4,23].”
BackgroundResult
Impact of Maze and Concomitant Mitral Valve Surgery on Clinical Outcomes
Wong, J. W. W., & Mak, K. (2006) · The Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2006.05.108 · Cited by 36
Intermediate to Long-Term Results of Radiofrequency Modified Maze Procedure as an Adjunct to Open-Heart Surgery
Beukema, W. P., Sie, H. T., Misier, A. R. R., Delnoy, P. P. H. M., Wellens, H. J. J., & Elvan, A. (2008) · The Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2008.06.064 · Cited by 36
Simplified technique for surgical ligation of the left atrial appendage in high-risk patients
Bakhtiary, F., Kleine, P., Martens, S., Dzemali, O., Doğan, S., Keller, H., Ackermann, H., Zierer, A. F., Özaslan, F., Wittlinger, T., et al. (2008) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2007.08.057 · Cited by 36
“Many studies reported incomplete closure of the LAA after surgical procedures, which may even increase the risk of embolization.(4,5) This work describes our initial experience with a new simple sur-”
Background
Monocyte–platelet aggregates and CD11b expression as markers for thrombogenicity in atrial fibrillation
Pfluecke, C., Tarnowski, D., Plichta, L., Berndt, K., Schumacher, P., Ulbrich, S., Forkmann, M., Christoph, M., Poitz, D. M., Wunderlich, C., et al. (2015) · Clinical Research in Cardiology · doi:10.1007/s00392-015-0922-4 · Cited by 36
Percutaneous left atrial appendage occlusion using different technologies in the United Kingdom: A multicenter registry
Betts, T. R., Leo, M., Panikker, S., Kanagaratnam, P., Koa‐Wing, M., Davies, D. W., Hildick‐Smith, D., Wynne, D. G., Ormerod, O. J., Segal, O. R., et al. (2016) · Catheterization and Cardiovascular Interventions · doi:10.1002/ccd.26782 · Cited by 36
“Based on the understanding that the left atrial appendage (LAA) is the source of thrombus for embolic events in people with nonvalvular AF [6], an alternative paradigm to lower the risk of thromboembolic stroke is to excise, close, or occlude the LAA.”
Background
Left Atrial Appendage Electrical Isolation as a Target in Atrial Fibrillation
Nishimura, M., Lupercio, F. A., & Hsu, J. C. (2019) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2019.02.009 · Cited by 36
“Surgical LAA excision or ligation at the time of cardiac surgery have been in practice for more than one-half a century (26,29).”
Background
Evaluation of left atrial deformation to predict left atrial stasis in patients with non-valvular atrial fibrillation – a pilot-study
Providencia, R. A., Faustino, A., Ferreira, M. J., Gonçalves, L. M. M., Trigo, J., Botelho, A., Barra, S., & Bovéda, S. (2013) · Cardiovascular Ultrasound · doi:10.1186/1476-7120-11-44 · Cited by 36
“Non-valvular atrial fibrillation (AF) is associated with stroke and peripheral embolism of cardiac origin [1] and over 90% of thrombi are thought to originate in the left atrial appendage (LAA) [2].”
Management of atrial fibrillation
Hersi, A. S., & Wyse, D. G. (2005) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2004.09.002 · Cited by 36
Obliteration of the leftatrial appendage forprevention of thromboembolism**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology.
Halperin, J. L., & Gomberg‐Maitland, M. (2003) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(03)00958-6 · Cited by 36
State of the Art in Left Atrial Appendage Occlusion
Garg, J., Kabra, R., Gopinathannair, R., Biase, L. D., Wang, D. D., Saw, J., Hahn, R. T., Freeman, J. V., Ellis, C. R., & Lakkireddy, D. (2025) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2024.10.024 · Cited by 35
The Left Atrial Appendage: Target for Stroke Reduction in Atrial Fibrillation
Ramlawi, B., Saleh, W. K. A., & Edgerton, J. R. (2015) · Methodist DeBakey Cardiovascular Journal · doi:10.14797/mdcj-11-2-100 · Cited by 35
“Even though it is still considered a “surgical” approach, this procedure has several potential advantages, including (1) procedure safety with minimal complications, (2) complete and consistent LAA exclusion with intraoperative TEE confirmation, (3) epicardial exclusion of LAA with no intracardiac foreign body, (4) De…”
Background
EWOLUTION: Design of a registry to evaluate real‐world clinical outcomes in patients with AF and high stroke risk‐treated with the WATCHMAN left atrial appendage closure technology
Boersma, L. V. A., Schmidt, B., Betts, T. R., Sievert, H., Tamburino, C., Teíger, E., Steín, K. M., & Bergmann, M. (2015) · Catheterization and Cardiovascular Interventions · doi:10.1002/ccd.26358 · Cited by 35
Left atrial appendage occlusion in high-risk patients with non-valvular atrial fibrillation
Berti, S. L., Pastormerlo, L. E., Rezzaghi, M., Trianni, G., Paradossi, U., Cerone, E., Ravani, M., Caterina, A. R. D., Rizza, A., & Palmieri, C. (2016) · Heart · doi:10.1136/heartjnl-2015-309150 · Cited by 35
Current Evidence-Based Understanding of the Epidemiology, Prevention, and Treatment of Atrial Fibrillation
Rogers, P. A., Bernard, M. L., Madias, C. A., Thihalolipavan, S., Estes, N. A. M., & Morin, D. P. (2017) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2017.06.001 · Cited by 36
An updated systematic review and meta‐analysis of early outcomes after left atrial appendage occlusion
Yerasi, C., Lazkani, M., Kolluru, P., Miriyala, V., Kim, J. H., Moole, H. V., Sawant, A. C., Morris, M. F., & Pershad, A. (2018) · Journal of Interventional Cardiology · doi:10.1111/joic.12502 · Cited by 36
“The left atrial appendage (LAA) is the source of most thrombi that cause stroke in non-valvular atrial fibrillation (NVAF).(3) Although Warfarin and new generation anticoagulants are effective in preventing systemic embolization and stroke in patients with”
Background
Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Cancer
Shabtaie, S. A., Tan, N. Y. L., Ward, R. C., Lewis, B. R., Yang, E. H., Holmes, D. R., & Herrmann, J. (2023) · JACC CardioOncology · doi:10.1016/j.jaccao.2022.10.016 · Cited by 35
“nuscript received January 24, 2022; revised manuscript received October tion within the left atrial appendage.(3,4) In patients with nonvalvular AF for whom oral anticoagulation is contraindicated or not felt to be desirable, left atrial appendage occlusion (LAAO) with a Watchman device”
Background
Concurrent prophylactic left atrial appendage exclusion: results from a randomized controlled trial pilot study☆
Nagpal, D., Torracca, L., Fumero, R., Denti, P., Cioni, M., & Alfieri, O. (2009) · European Journal of Cardio-Thoracic Surgery · doi:10.1016/j.ejcts.2009.03.024 · Cited by 35
“As noted above, previous series have not shown any significant arrhythmic or hemodynamic problems following left atrial appendage ligation or exclusion [3,12,13,17].”
Potential applicability and utilization of left atrial appendage occlusion devices in patients with atrial fibrillation
Fountain, R. B., Holmes, D. R., Hodgson, P. K., Chandrasekaran, K., Tassel, R. A. V., & Sick, P. B. (2006) · American Heart Journal · doi:10.1016/j.ahj.2006.05.001 · Cited by 35
Left Atrial Appendage Closure to Prevent Stroke in Patients With Atrial Fibrillation
Price, M. J., & Valderrábano, M. (2014) · Circulation · doi:10.1161/circulationaha.114.009060 · Cited by 34
“found in patients with nonvalvular AF and stroke are in the LAA supports this mechanistic sequence.(11) In addition, low”
Background
Cardiac Computed Tomography for Left Atrial Appendage Occlusion
Korsholm, K., Jensen, J. M., & Nielsen‐Kudsk, J. E. (2018) · Interventional Cardiology Clinics · doi:10.1016/j.iccl.2017.12.004 · Cited by 34
Left atrial appendage closure in patients with chronic kidney disease: results from the German multicentre LAARGE registry
Fastner, C., Brachmann, J., Lewalter, T., Zeymer, U., Sievert, H., Borggrefe, M. M., Nienaber, C. A., Weiß, C. H., Pleger, S. T., İnce, H., et al. (2020) · Clinical Research in Cardiology · doi:10.1007/s00392-020-01638-5 · Cited by 37
A novel device for left atrial appendage exclusion
Kamohara, K., Fukamachi, K., Ootaki, Y., Akiyama, M., Zahr, F. E., Kopcak, M. W., Dessoffy, R., Popović, Z., Daimon, M., Cosgrove, D. M., et al. (2005) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2005.08.019 · Cited by 34
“When compared with epicardial stapling devices, the AED offers 2 advantages: (1) easy reapplication that ensures proper placement onto the base of the LAA and ( 2 ) elimination of the risk of bleeding that may originate along the occlusion (staple) line.”
Background
Prevention of stroke in patients with atrial fibrillation: current strategies and future directions
Hohnloser, S. H., Duray, G. Z., Baber, U., & Halperin, J. L. (2008) · European Heart Journal Supplements · doi:10.1093/eurheartj/sun029 · Cited by 34
Left Atrial Appendage Occlusion vs Standard of Care After Ischemic Stroke Despite Anticoagulation
Maarse, M., Seiffge, D. J., Werring, D. J., Boersma, L. V. A., STR-OAC LAAO Group, Macha, K., Takagi, M., Tsivgoulis, G. K., Bonetti, B., Arihiro, S., et al. (2024) · JAMA Neurology · doi:10.1001/jamaneurol.2024.2882 · Cited by 33
Pulmonary vein stump thrombus: an early complication following upper division segmentectomy of the left lung
Asai, K., Mochizuki, T., Iizuka, S., Momiki, S., & Suzuki, K. Z. (2013) · General Thoracic and Cardiovascular Surgery · doi:10.1007/s11748-013-0229-1 · Cited by 33
“Approximately, 90 % of the thrombi responsible for embolic events originate in the left atrial appendage in patients with nonvalvular atrial fibrillation [12].”
Background
Left atrial appendage closure monitoring without sedation: a pilot study using intracardiac echocardiography through the oesophageal route
Ternacle, J., Lellouche, N., Deux, J., Dubois‐Randé, J., Teíger, E., & Lim, P. (2014) · EuroIntervention · doi:10.4244/eijy14m07_17 · Cited by 33
Epicardial clip occlusion of the left atrial appendage during cardiac surgery provides optimal surgical results and long-term stability†
Kurfirst, V., Mokráček, A., Čanádyová, J., Frána, R., & Zeman, P. (2017) · Interactive Cardiovascular and Thoracic Surgery · doi:10.1093/icvts/ivx065 · Cited by 33

Authors: Blackshear, J. L., & Odell, J. A.
Affiliations: Mayo Clinic (US)
Venue: The Annals of Thoracic Surgery
Publisher: Elsevier BV
Published: 1996-02
Volume: 61
Issue: 2
Pages: 755-759
ISSN: 0003-4975 (ISSN-L)
DOI: 10.1016/0003-4975(95)00887-x
OpenAlex: W2053482681
Cited by: 1,686
References: 61
Citations by year: 2026: 78 · 2025: 68 · 2024: 98 · 2023: 112 · 2022: 93 · 2021: 108 · 2020: 126 · 2019: 100 · 2018: 111 · 2017: 121 · 2016: 100 · 2015: 125 · 2014: 81 · 2013: 75 · 2012: 61
FWCI: 0.91
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
Locations: The Annals of Thoracic Surgery (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac tumors and thrombi
Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cardiovascular and Diving-Related Complications
Keywords: atrial fibrillation, postoperative stroke, stroke prevention, left atrial thrombus, non-valvular atrial fibrillation, cardiac surgery, mitral valve surgery, maze procedure, anticoagulation
MeSH terms: Contraindications, Aged, Atrial Fibrillation, Cerebrovascular Disorders, Heart Atria, Heart Diseases, Humans, Mitral Valve Stenosis, Postoperative Complications, Thrombosis, Warfarin

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Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation

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