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Surgical atrial appendage closure: time for a randomized study

Chirurgischer Vorhofohrverschluss – Zeit für eine randomisierte Studie

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Abstract

Atrial fibrillation (AF) is the most common arrhythmia and is assumed to affect more than 30 million people worldwide. Studies report that the left atrial appendage (LAA) plays an important role in thrombus formation and is considered the embolic source in 90% of affected patients with non-valvular and 57% with valvular AF. Oral anticoagulants have been the standard of care for stroke prevention in patients with AF for decades. However, bleeding complications and noncompliance are barriers to effective embolic protection. Therefore, as an alternative to conventional anti-thrombotic therapy, surgical LAA occlusion, which may lead to a reduced risk of thromboembolism, has received increasing attention. However, the procedure can be associated with additional risks such as prolonged operation time, damage to the circumflex coronary artery, and incomplete LAA occlusion. This review discusses some of the observational studies that have examined the impact of LAA occlusion on stroke, the LAAOS III (Left Atrial Appendage Occlusion Study) trial, which provided definitive evidence for the benefit of surgical LAA occlusion on ischemic stroke, which surgical methods are safe and effective for LAA occlusion, and whether oral anticoagulation can be stopped after surgical removal of the LAA.

Zusammenfassung

Vorhofflimmern ist die häufigste Arrhythmie und betrifft vermutlich mehr als 30 Mio. Menschen weltweit. Studien berichten, dass das linke Herzohr („left atrial appendage“ [LAA]) eine wichtige Rolle bei der Thrombusbildung spielt und als Emboliequelle bei 90 % der Patienten mit nichtvalvulärem und 57 % der Patienten mit valvulärem Vorhofflimmern gilt. Orale Antikoagulanzien sind seit Jahrzehnten der Behandlungsstandard zur Schlaganfallprävention bei Patienten mit Vorhofflimmern. Blutungskomplikationen und Noncompliance sind jedoch Hindernisse für einen wirksamen Schutz vor Embolien. Als Alternative zur konventionellen antithrombotischen Therapie erfährt daher der chirurgische LAA-Verschluss zunehmende Aufmerksamkeit; dieser kann ebenfalls das Thromboembolierisiko verringern. Allerdings birgt das Verfahren auch Risiken wie eine verlängerte Operationszeit, eine Beschädigung des Ramus circumflexus und einen unvollständigen LAA-Verschluss. In dieser Übersicht diskutieren wir einige der Beobachtungsstudien, die die Auswirkungen des LAA-Verschlusses auf Schlaganfälle untersuchten, und die LAAOS-III-Studie (Left Atrial Appendage Occlusion Study), die endgültige Beweise für den Nutzen des chirurgischen LAA-Verschlusses in Bezug auf ischämische Schlaganfälle lieferte. Wir erörtern, welche Methoden zum Verschluss des LAA sicher und wirksam sind und ob die orale Antikoagulation nach der chirurgischen Entfernung des LAA beendet werden kann.

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Authors and Affiliations

  1. Department of Cardiovascular Surgery, Robert Bosch Hospital Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany

    Magdalena Rufa MD, Nora Göbel MD & Ulrich F. W. Franke PhD

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  1. Magdalena Rufa MD
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  2. Nora Göbel MD
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  3. Ulrich F. W. Franke PhD
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Correspondence to Magdalena Rufa MD.

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M. Rufa, N. Göbel, and U. F. W. Franke declare that they have no conflicts of interest.

This article does not contain any studies with human participants or animal subjects performed by any of the authors.

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Rufa, M., Göbel, N. & Franke, U.F.W. Surgical atrial appendage closure: time for a randomized study. Herzschr Elektrophys 33, 386–390 (2022). https://doi.org/10.1007/s00399-022-00903-6

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