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Ann Thorac Surg 1996;61:515
© 1996 The Society of Thoracic Surgeons
Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
Odell, Blackshear, and their associates [1, 2] provide a convincing argument that in patients with atrial fibrillation, atrial thrombi often arise from the left atrial appendage, removal of the appendage should reduce the risk of stroke, and it is technically feasible to achieve this with thoracoscopic technique. The challenge is to determine which patients would be appropriate candidates for this approach, the potential risks of the operation relative to its benefit, and the impact on the risk of stroke.
For patients who require a cardiac operation the risk of stroke is increased from 1.4% to 3.3% by the presence of atrial fibrillation during the postoperative period [3]. Introperative truncation of the left atrial appendage would eliminate an important nidus of thrombus formation and would be expected to reduce thromboembolic complications, especially in patients with nonrheumatic heart disease; however, it could be difficult to demonstrate benefit in a randomized trial because of the relatively low incidence of embolic complications.
Blackshear and Odell [1] have proposed that thoracoscopic obliteration of the left atrial appendage may be appropriate for high-risk patients who are unsuitable for anticoagulation therapy and are not candidates for the maze operation. Most would agree that the patients at highest risk are those who have had recent embolic events. Prospective identification of patients at risk is more difficult, and the transesophageal echocardiographic criteria used to identify high-risk patients are still evolving. In patients with atrial fibrillation who are referred for cardioversion, the incidence of thrombi in the left atrium is 8% to 21% [4–6]. Although not all left atrial thrombi embolize, one would expect these patients to be at higher risk. Spontaneous echo contrast is another attribute that has been used to assess risk, but the positive predictive value is low [6]. Further study is needed to determine whether these or other criteria could be used to prospectively identify patients at greatest risk of embolic complications who would be appropriate candidates for obliteration of the left atrial appendage.
Several factors may limit the number of patients who are suitable candidates for thoracoscopic obliteration of the left atrial appendage. Patients with contraindications to warfarin frequently are elderly or have complex medical problems that make them poor candidates for an operation. Moreover, many patients with atrial fibrillation have had prior cardiac operations. In this group, the presence of fibrotic tissue within and outside the pericardial space would greatly complicate a thoracoscopic approach and could be prohibitive.
Although the concept of thoracoscopic obliteration of the left atrial appendage offers promise for the reduction of embolic complications in patients with atrial fibrillation, further study is needed to improve identification of those who are most likely to benefit from this operation. Moreover, Blackshear, Odell, and their associates have emphasized the need for clinical trials to establish the efficacy and safety of thoracoscopic obliteration of the left atrial appendage. It is especially important that these issues be resolved before the concept becomes practice in the management of atrial fibrillation.
Footnotes
Address reprint requests to Dr Lindsay, Cardiovascular Division, Washington University School of Medicine, 660 S. Euclid Ave, Box 8086, St. Louis, MO 63110.
References
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