Skip to main content
SpringerLink
Log in

Left atrial appendage obliteration in atrial fibrillation patients undergoing bioprosthetic mitral valve replacement

Obliteration des linken Herzohrs bei Patienten mit Vorhofflimmern und bioprothetischem Mitralklappenersatz

  • Original article
  • Published:
Herz Aims and scope Submit manuscript

Abstract

Background

Left atrial appendage (LAA) obliteration is a proven stroke-preventive measure for patients with nonvalvular atrial fibrillation (AF). However, the efficacy of LAA obliteration for patients with AF after bioprosthetic mitral valve replacement (MVR) remains unclear.

Aim

This study aimed to estimate the efficacy of LAA obliteration in preventing embolism and to investigate the predictors of thromboembolism after bioprosthetic MVR.

Methods

We retrospectively studied 173 AF subjects with bioprosthetic MVR; among them, 81 subjects underwent LAA obliteration using an endocardial running suture method. The main outcome measure was the occurrence of thrombosis events (TEs). The mean follow-up time was 40 ± 17 months.

Results

AF rhythm was observed in 136 patients postoperatively. The incidence rate of TEs was 13.97 % for postoperative AF subjects; a dilated left atrium (LA; > 49.5 mm) was identified as an independent risk factor of TEs (OR = 10.619, 95 % CI = 2.754–40.94, p = 0.001). For postoperative AF patients with or without LAA, the incidence rate of TEs was 15.8 % (9/57) and 12.7 % (10/79; p = 0.603), respectively. The incidence rate of TEs was 2.7 % (1/36) and 4.2 % (2/48) for the subgroup patients with a left atrial diameter of < 49.5 mm, and 38.1 % (8/21) and 25.8 % (8/31) for those with a left atrial diameter of > 49.5 mm (p = 0.346).

Conclusion

Surgical LAA obliteration in patients with valvular AF undergoing bioprosthetic MVR did not reduce TEs, even when the CHA2DS2-VASc score (a score for estimating the risk of stroke in AF) was ≥ 2 points.

Zusammenfassung

Hintergrund

Die Obliteration des linken Herzohrs („left atrial appendage“, LAA) ist nachgewiesenermaßen ein Verfahren zur Prävention des Schlaganfalls bei Patienten mit nichtvalvulärem Vorhofflimmern (VF). Die Wirksamkeit der LAA-Obliteration bei Patienten mit VF nach Mitralklappenersatz („mitral valve replacement“, MVR) mit einer Bioprothese bleibt jedoch unklar.

Ziel

Die vorliegende Studie zielt darauf ab, die Wirksamkeit der LAA-Obliteration bei der Verhütung von Embolien abzuschätzen und Prädiktoren der Thromboembolie nach bioprothetischem MVR zu untersuchen.

Methoden

Retrospektiv wurden 173 Patienten mit VF und bioprothetischem MVR untersucht, in 81 Fällen davon war eine LAA-Obliteration mit fortlaufender Endokardnaht erfolgt. Hauptendpunktparameter war das Auftreten thrombotischer Ereignisse (TE). Die Nachbeobachtungsdauer lag im Durchschnitt bei 40 ± 17 Monaten.

Ergebnisse

Postoperativ bestand bei 136 Patienten ein VF. Die TE-Inzidenzrate betrug 13,97 % bei den Teilnehmern mit postoperativem VF; ein dilatierter linken Vorhof (> 49,5 mm) wurde als unabhängiger Risikofaktor für TE ermittelt (Odds Ratio, OR: 10,619; 95 %-Konfidenzintervall: 2,754–40,94; p = 0,001). Für Patienten mit postoperativem VF mit bzw. ohne LAA lag die Inzidenzrate für TE bei 15,8 % (9/57) bzw. 12,7 % (10/79; p = 0,603), und bei 2,7 % (1/36) bzw. 4,2 % (2/48) für die Untergruppe mit einem linken Vorhof < 49,5 mm; dagegen bei 38,1 % (8/21) bzw. 25,8 % (8/31) für Patienten mit einem linken Vorhof > 49,5 mm (p = 0,346).

Schlussfolgerung

Durch eine chirurgische LAA-Obliteration bei Patienten mit valvulärem VF und bioprothetischem MVR wurden TE nicht vermindert, selbst wenn der CHA2DS2-VASc-Score (Score zur Abschätzung des Schlaganfallrisikos bei VF) bei ≥ 2 Punkten lag.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Emmert MY, Puippe G, Baumuller S et al (2014) Safe, effective and durable epicardial left atrial appendage clip occlusion in patients with atrial fibrillation undergoing cardiac surgery: first long-term results from a prospective device trial. Eur J Cardiothorac Surg 45(1):126–131

    Article  PubMed  Google Scholar 

  2. Sick PB, Schuler G, Hauptmann KE et al (2007) Initial worldwide experience with the left atrial appendage system for stroke prevention in atrial fibrillation. J Am Coll Cardiol 49(13):1490–1495

    Article  PubMed  Google Scholar 

  3. Syed FF, Friedman PA (2014) Left atrial appendage closure for stroke prevention: emerging technologies. Card Electrophysiol Clin 6(1):141–160

    Article  Google Scholar 

  4. Gonzalez-Lavin L, Tandon AP, Chi S et al (1984) The risk of thromboembolism and hemorrhage following mitral valve replacement. A comparative analysis between the porcine xenograft valve and Ionescu-Shiley bovine pericardial valve. J Thorac Cardiovasc Surg 87(3):340–351

    CAS  PubMed  Google Scholar 

  5. Williams JB, Karp RB, Kirklin JW et al (1980) Considerations in selection and management of patients undergoing valve replacement with glutaraldehyde-fixed porcine bioprotheses. Ann Thorac Surg 30(3):247–258

    Article  CAS  PubMed  Google Scholar 

  6. Blackshear JL, Odell JA (1996) Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 61:755–759

    Article  CAS  PubMed  Google Scholar 

  7. Garcia-Fernandez MA, Perez-David E, Quiles J et al (2003) Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol 42(7):1253–1258

    Article  PubMed  Google Scholar 

  8. January CT, Wann LS, Alpert JS et al (2014) 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 21(64):e1–e76

    Article  Google Scholar 

  9. Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I (2000) Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol 36(2):468–471

    Article  CAS  PubMed  Google Scholar 

  10. Lynch M, Shanewise JS, Chang GL, Martin RP, Clements SD (1997) Recanalization of the left atrial appendage demonstrated by transesophageal echocardiography. Ann Thorac Surg 63(6):1774–1775

    Article  CAS  PubMed  Google Scholar 

  11. Almahameed ST, Khan M, Zuzek RW et al (2007) Left atrial appendage exclusion and the risk of thromboembolic events following mitral valve surgery. J Cardiovasc Electrophysiol 18(4):364–366

    Article  PubMed  Google Scholar 

  12. Mahajan R, Brooks AG, Sullivan T et al (2012) Importance of the underlying substrate in determining thrombus location in atrial fibrillation: implications for left atrial appendage closure. Heart 98(15):1120–1126

    Article  PubMed  Google Scholar 

  13. Habara S, Dote K, Kato M et al (2007) Prediction of left atrial appendage thrombi in non-valvular atrial fibrillation. Eur Heart J 28(18):2217–2222

    Article  CAS  PubMed  Google Scholar 

  14. Burstein B, Nattel S (2008) Atrial fibrosis: mechanisms and clinical relevance in atrial fibrillation. J Am Coll Cardiol 51(8):802–809

    Article  CAS  PubMed  Google Scholar 

  15. Viles-Gonzalez JF, Kar S, Douglas P et al (2012) The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol 59(10):923–929

    Article  PubMed  Google Scholar 

  16. Goldberg YH (2008) Relationship between atrial fibrillation and left atrial size. J Am Coll Cardiol 51(7):776 (author reply 776–777)

    Article  PubMed  Google Scholar 

  17. Chinali M, de Simone G, Roman MJ et al (2005) Left atrial systolic force and cardiovascular outcome. The Strong Heart Study. Am J Hypertens 18(12 Pt 1):1570–1576 (discussion 1577)

    Article  PubMed  Google Scholar 

  18. Henry WL, Morganroth J, Pearlman AS et al (1976) Relation between echocardiographically determined left atrial size and atrial fibrillation. Circulation 53(2):273–279

    Article  CAS  PubMed  Google Scholar 

  19. Knackstedt C, Gramley F, Schimpf T et al (2008) Association of echocardiographic atrial size and atrial fibrosis in a sequential model of congestive heart failure and atrial fibrillation. Cardiovasc Pathol 17(5):318–324

    Article  PubMed  Google Scholar 

  20. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001) Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 285(22):2864–2870

    Article  CAS  PubMed  Google Scholar 

  21. January CT, Wann LS, Alpert JS et al (2014) 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 130(23):2071–2104

    Article  PubMed  Google Scholar 

  22. Investigators TSPiAF (1992) Predictors of thromboembolism in atrial fibrillation: II. Echocardiographic features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators. Ann Intern Med 116(1):6–12

    Article  Google Scholar 

  23. Investigators TSPiAF (1992) Predictors of thromboembolism in atrial fibrillation: I. Clinical features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators. Ann Intern Med 116(1):1–5

    Article  Google Scholar 

  24. Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH (2012) Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e576S–e600S

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  25. Daccarett M, Badger TJ, Akoum N et al (2011) Association of left atrial fibrosis detected by delayed-enhancement magnetic resonance imaging and the risk of stroke in patients with atrial fibrillation. J Am Coll Cardiol 57(7):831–838

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiac Surgery, Atrial Fibrillation Center, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, 100029, Chaoyang District, Beijing, China

    X.P. Min, T.Y. Zhu, J. Han, Y. Li & X. Meng

Authors
  1. X.P. Min
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. T.Y. Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J. Han
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Y. Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. X. Meng
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to X. Meng.

Ethics declarations

Conflict of interest

X-P. Min, T-Y. Zhu, J. Han, Y. Li, and X. Meng state that there are no conflicts of interest. All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Min, X., Zhu, T., Han, J. et al. Left atrial appendage obliteration in atrial fibrillation patients undergoing bioprosthetic mitral valve replacement. Herz 41, 87–94 (2016). https://doi.org/10.1007/s00059-015-4350-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00059-015-4350-z

Keywords

Schlüsselwörter

Search

Navigation