IMAGES IN CARDIOTHORACIC SURGERY
Huge Left Atrial Appendage After an Incomplete Surgical Ligation and Successful Catheter Ablation of Atrial Fibrillation Takehiro Kimura, MD, PhD, Kohei Inagawa, MD, PhD, Kojiro Tanimoto, MD, PhD, and Seiji Takatsuki, MD, PhD
FEATURE ARTICLES
Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
Fig 1.
60-year-old woman (CHADS2 score ¼ 0) received a mitral valve replacement (25 mm, ATS Medical, Inc.) with a modified DeVega’s tricuspid annuloplasty for rheumatic heart disease. After an electric pulmonary vein (PV) isolation with the use of AtriCure, the left atrium (LA) was incised with the patient under cardioplegic arrest. The left atrial appendage (LAA) was ligated with an internal running 4-0 Prolene suture before the valve replacement and plasty. She was referred to our facility to undergo catheter ablation of atrial arrhythmias 6 months later. Cardiac computed tomography revealed both PV stenosis and a huge LAA with a thin neck on left anterior oblique view (Fig 1A) and posteroanterior view (Fig 1B). The lobe was 32.0 41.1 20.2 mm, with a volume of 11.8 cm3. The neck was 5.7 mm 4.5 mm with an area of 16.8 mm2 (Fig 1C, arrow). The flow
A
Address correspondence to Dr Kimura, 35 Shinanomachi Shinjuku-ku, Tokyo, Japan 160-8582; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
velocity of the LAA ostium was approximately 120 cm/ sec during atrial fibrillation without any evidence of spontaneous echocardiographic contrast (Fig 1D). After the electric reisolation of the PVs and linear ablation, there was no relapse of arrhythmias during 6 months of follow-up. Stenosis at the neck can cause a subsequent deterioration in the LAA dilatation, and an additional closing maneuver would also be difficult. An incomplete surgical LAA ligation was reported to occur in almost one third of patients after operation [1], which should be minimized to avoid controversy regarding anticoagulation for incompletely ligated LAAs.
Reference 1. Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol 2000;36:468–71. Ann Thorac Surg 2015;99:1826 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.056
Huge Left Atrial Appendage After an Incomplete Surgical Ligation and Successful Catheter Ablation of Atrial Fibrillation Takehiro Kimura, MD, PhD, Kohei Inagawa, MD, PhD, Kojiro Tanimoto, MD, PhD, and Seiji Takatsuki, MD, PhD
FEATURE ARTICLES
Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
Fig 1.
60-year-old woman (CHADS2 score ¼ 0) received a mitral valve replacement (25 mm, ATS Medical, Inc.) with a modified DeVega’s tricuspid annuloplasty for rheumatic heart disease. After an electric pulmonary vein (PV) isolation with the use of AtriCure, the left atrium (LA) was incised with the patient under cardioplegic arrest. The left atrial appendage (LAA) was ligated with an internal running 4-0 Prolene suture before the valve replacement and plasty. She was referred to our facility to undergo catheter ablation of atrial arrhythmias 6 months later. Cardiac computed tomography revealed both PV stenosis and a huge LAA with a thin neck on left anterior oblique view (Fig 1A) and posteroanterior view (Fig 1B). The lobe was 32.0 41.1 20.2 mm, with a volume of 11.8 cm3. The neck was 5.7 mm 4.5 mm with an area of 16.8 mm2 (Fig 1C, arrow). The flow
A
Address correspondence to Dr Kimura, 35 Shinanomachi Shinjuku-ku, Tokyo, Japan 160-8582; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
velocity of the LAA ostium was approximately 120 cm/ sec during atrial fibrillation without any evidence of spontaneous echocardiographic contrast (Fig 1D). After the electric reisolation of the PVs and linear ablation, there was no relapse of arrhythmias during 6 months of follow-up. Stenosis at the neck can cause a subsequent deterioration in the LAA dilatation, and an additional closing maneuver would also be difficult. An incomplete surgical LAA ligation was reported to occur in almost one third of patients after operation [1], which should be minimized to avoid controversy regarding anticoagulation for incompletely ligated LAAs.
Reference 1. Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol 2000;36:468–71. Ann Thorac Surg 2015;99:1826 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.056
