Postoperative Transesophageal Echocardiographic Evaluation of Surgical Left Atrial Appendage Exclusion: Characterization and Predictors of Success

Background

Mounting evidence suggests surgical left atrial appendage (LAA) exclusion reduces stroke risk in patients with atrial fibrillation. Prior older research suggests that LAA exclusion is often incomplete, but few transesophageal echocardiogram (TEE) data exist evaluating LAA remnants.

Methods

We analyzed 121 patients with an available postoperative TEE who underwent LAA exclusion by surgical excision (SE), AtriClip occlusion (AO), or Tiger Paw occlusion (TO). TEE images were assessed for LAA remnant depths, presence of flow into remnant, and visible suture, thrombus, or pectinate. Successful LAA exclusion was defined as a remnant with depth past LAA ostium <1 cm in all available imaging angles.

Results

Left atrial appendage exclusion was successful in 99/121 (82%) patients. Success varied numerically but not statistically by technique; 73/85 (86%), 22/29 (76%), 4/7 (57%) in the SE, AO, and TO groups, respectively. SE group had similar mean and max (cm) remnant depths (0.56 ± 0.32 and 0.65 ± 0.38) compared to the AO group (0.68 ± 0.38 and 0.81 ± 0.49) and TO group (0.69 ± 0.30 and 0.83 ± 0.40). Flow into LAA remnant was seen in 4.4% (SE), 15.0% (AO), and 20.0% (TO). Residual pectinate was seen in 18.8% (SE), 13.8% (AO), and 14.3% (TO); 8% in SE group had visible suture. Thrombus was seen in 2 cases within the SE group. In multivariable models, diabetes and heart failure predicted max LAA depth.

Conclusions

Postoperative TEE examination of LAA remnants revealed a relatively high failure rate by current standards. More data are needed to evaluate the clinical relevance of LAA remnant characteristics.