Author + information
- Arash Aryana, MD∗ ( and )
- André d'Avila, MD, PhD
- ↵∗Regional Cardiology Associates and the Mercy Heart & Vascular Institute, 3941 J Street, Suite #350, Sacramento, California 95819
We read with great interest the Image in Interventionby Matsumoto et al. (1), published in the February 2013 issue of JACC: Cardiovascular Interventions.In it, the authors describe a procedure for percutaneous endocardial occlusion of incompletely surgically ligated left atrial appendage (ISLL) using a septal occluder device guided by transesophageal echocardiography (TEE) and angiography in a patient with atrial fibrillation (AF) previously treated with a surgical maze procedure, mitral and tricuspid valve repair, and attempted surgical ligation of the left atrial appendage. In addition, they argue that the proposed approach can “reduce the risk of thromboembolism and stroke.”
Similarly, our group has recently published a paper on the safety and feasibility of this technique (2). Although the clinical significance of ISLL warrants further investigation, it is believed to be associated with an increased risk of thromboembolism. Moreover, it is believed that ISLL may actually be worse than no occlusion at all, given that reduced blood flow in and out of a “stenotic” left atrial appendage may in fact promote a higher risk of thrombus formation inside this structure (3). Consistent with this, 3 patients in our series presented with an early embolic event following ISLL despite a CHADS2score ≤1 and antiplatelet therapy. In addition, we have observed an inverse relationship between embolic stroke risk and the size of the ISLL neck diameter in our patients.
We, too, have not observed any embolic events in our small cohort of AF patients who underwent percutaneous endocardial ISLL occlusion, subsequently off oral anticoagulation therapy, during 8 ± 2 months of follow-up. Nevertheless, we have remained cautious in offering hasty conclusions regarding long-term stroke risk reduction through such an approach. An important element that needs to be taken into consideration is the underlying disease substrate. That is, although atrial thrombi likely originate inside the left atrial appendage in nearly 90% of patients with nonvalvular AF, the same is true for <50% of patients with valvular AF, as shown in a recent systematic review of 34 studies (4). Hence, firm conclusions regarding stroke risk reduction in the setting of AF and cardiac valvular pathology derived purely on the basis of a single case report seems premature.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Matsumoto T.,
- Nakamura M.,
- Yeow W.L.,
- Siegel R.J.,
- Kar S.
- Mahajan R.,
- Brooks A.G.,
- Sullivan T.,
- et al.