European Journal of Echocardiography 2008 9(1):194-195; doi:10.1093/ejechocard/jem069
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Left atrial appendage can still cause clinical events after ligation
Cem Koz,
Oben Baysan*,
Mehmet Yoku
o
lu,
Mehmet Uzun and
Celal Genc
Department of Cardiology, Gulhane Medical Military Academy, Etlik, Ankara, Turkey
Received 21 March 2007; accepted after revision 9 September 2007.
* Corresponding author. Mehterler Sk. Erkilinc Apt. No:7/7, Etlik, Ankara, Turkey. Tel: +90 312 325 86 41; fax: +90 312 304 42 50. E-mail address: obenbaysan{at}gmail.com
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Abstract
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We present a 71-year-old female patient with transient ischaemic
attack. A thrombus located at the stump of previously ligated
left atrial appendage was suspected as the cause of event.
Keywords: Left atrial appendage ligation; Thrombus
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Introduction
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On the basis of previous findings, a thrombo-embolic event,
although rare, can be anticipated after left atrial appendage
(LAA) ligation.
1,2 We report a patient with transient ischaemic
attack without any risk factors except a thrombus located at
the previously ligated LAA stump.
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Case report
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A 71-year-old female who had previous mitral valve surgery with
St Jude No. 23 valve 2 years before the event was admitted to
our emergency service with near-syncope and dizziness. According
to her previous registration file, LAA was ligated with suture
technique at that time. The patient has been on warfarin treatment
since the operation. Apart from mechanical S1 sound and weakness
of the left arm, her physical examination was unremarkable.
ECG was in sinus rhythm with non-specific ST-T changes. The
INR value was 2.7. The transthoracic echocardiographic examination
revealed that the functions of both ventricles were normal (left
ventricular ejection fraction: 54%) with normally functioning
mitral prosthetic valve (mitral valve area was 2.4 cm
2).
A cerebral embolic event was suspected following an emergency
neurology consultation; however, the computerized tomography
data were not diagnostic. Consequently, we decided to perform
transoesophageal echocardiographic examination. Although the
mitral valve was seen to have mild central regurgitation, there
was a mass suggesting thrombus located at the LAA stump (
Figure 1).
Any sign of jet traversing the ligated LAA-LA body border has
not been determined. Her symptoms disappeared soon after admission
and the diagnosis of transient ischaemic attack was confirmed
by a senior neurologist. On the basis of these findings, we
intensified the warfarin therapy with target INR 3.5 and added
low-dose aspirin to treatment plan. She is still on follow-up
period with no recurrent event.
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Discussion
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Left atrial appendage is regarded as the major site of embolic
events in patients with atrial fibrillation.
3 Preventive measures
against these events include various drugs and methods such
as warfarin and LAA ligation that can be used during mitral
valve or bypass surgery.
4
Although direct LAA suturing method is a frequently used approach in clinical practice, it is proposed to have 36% incomplete ligation rate.5 Use of stapling device has better complete ligation rate (72%), but both techniques have thrombo-embolic event rate that cannot be neglected.1,2 Incomplete LAA ligation and/or absence of effective anticoagulation treatment have been reported as the major risk factors for embolic events in patients with this procedure.2,6 However, any sign suggesting incomplete LAA ligation was not detected in this case and INR level was within target levels.7 Srichai et al.8 reported an inverted LAA mimicking thrombus, but the mobile mass in that report was located at the LA limbus and was associated with high mitral regurgitation jet. We excluded this possibility in our case due to different anatomic location, immobility of the mass, and the absence of regurgitant jet. What was responsible for thrombus in our case was not clear but we speculated that minor LA tears during mitral valve surgery and LAA ligation might have led to the lesion. In our opinion, LAA ligation should be performed with less invasive techniques which do not damage LA as recently reported by Kiaii et al.9
Conflict of interest: none declared.
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Supplementary material
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Supplementary data associated with this article can be found in the online version.
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References
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- Healey JS, Crystal E, Lamy A, Teoh K, Semelhago L, Hohnloser SH, et al. Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke. Am Heart J (2005) 150:288–293.[CrossRef][Web of Science][Medline]
- Almahameed ST, Khan M, Zuzek RW, Juratli N, Belden WA, Asher CR, et al. Left atrial appendage exclusion and the risk of thromboembolic events following mitral valve surgery. J Cardiovasc Electrophysiol (2007) 18:364–366.[CrossRef][Web of Science][Medline]
- Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg (1996) 61:755–759.[Abstract/Free Full Text]
- Artang R, Vidaillet H. Alternatives to warfarin for thromboembolism prophylaxis in nonrheumatic atrial fibrillation. J Interv Card Electrophysiol (2004) 10((Suppl 1)):33–44.[CrossRef][Web of Science][Medline]
- 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) 36:468–471.[Abstract/Free Full Text]
- Garcia-Fernandez MA, Perez-David E, Quiles J, Peralta J, Garcia-Rojas I, Bermejo J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol (2003) 42:1253–1258.[Abstract/Free Full Text]
- Gohlke-Barwolf C, Acar J, Oakley C, Butchart E, Burckhart D, Bodnar E, et al. Guidelines for prevention of thromboembolic events in valvular heart disease. Study Group of the Working Group on Valvular Heart Disease of the European Society of Cardiology. Eur Heart J (1995) 16:1320–1330.[Free Full Text]
- Srichai MB, Griffin B, Banbury M, Sabik EM. Images in cardiovascular medicine. Inverted left atrial appendage ligation mimicking thrombus. Circulation (2005) 111:e178–e179.[Free Full Text]
- Kiaii B, McClure RS, Skanes AC, Ross IG, Spouge AR, Swinamer S, et al. Robotic-assisted left atrial ligation for stroke reduction in chronic atrial fibrillation: a case report. Heart Surg Forum (2006) 9:E533–E535.[CrossRef][Web of Science][Medline]
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Abstract
Introduction