European Journal of Echocardiography Advance Access published online on March 19, 2007
European Journal of Echocardiography, doi:10.1016/j.euje.2007.01.006
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 thrombus outside of a ‘successful’ ligation
Robert Donnino,
Paul A. Tunick and
Itzhak Kronzon*
New York University Medical Center, Department of Medicine, Cardiology Division, Echocardiography Laboratory, 560 First Avenue, New York, NY 10016, USA
Received 31 October 2006; accepted after revision 20 January 2007.
* Corresponding author. Tel: +1 (212) 263 5665; fax: +1 (212) 263 8461. E-mail address: itzhak.kronzon{at}med.nyu.edu (I. Kronzon).
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Abstract
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A 79-year-old woman with severe aortic stenosis underwent aortic
valve replacement surgery, and had ligation of the left atrial
appendage (LAA) using an epicardial approach. On a post-operative
echocardiographic evaluation, the distal portion of the LAA
was excluded, leaving no communication with the left atrium.
The proximal portion of the LAA, however, was in continuity
with the circulation and a large thrombus was present within
it. While previous reports of incomplete LAA ligation have involved
disruption of the suture line, this present report describes
a case of incomplete ligation due to persistence of the proximal
portion of the appendage. Thus, thrombus formation occurred
despite a ‘successful’ epicardial exclusion of the
distal LAA.
Keywords: Left atrial appendage; Incomplete ligation; Thrombus; Transesophageal echocardiography
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Introduction
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The left atrial appendage (LAA) is a frequent site of thrombus
formation in patients with atrial fibrillation and/or valvular
disease. Ligation of the LAA during valvular surgery is often
done to exclude the LAA and eliminate the risk of embolic complications.
Previous reports have described incomplete ligations leading
to persistent communication of the LAA with the body of the
left atrium.
1,2
In this present case, we describe a patient who developed a thrombus in the proximal portion of the LAA despite a ‘successful’ ligation of the distal half of the appendage.
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Case report
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A 79-year-old woman with severe aortic stenosis underwent aortic
valve replacement surgery with coronary artery bypass grafting.
During the surgery, the patient was found to have a thrombus
in the left atrial appendage. The appendage was explored, and
was then ligated using external purse string suturing from the
epicardial surface. Several days later, still during the in-hospital
post-operative period, the patient developed atrial fibrillation.
Electrical cardioversion was planned, and the patient was referred
for echocardiographic evaluation to exclude intracardiac thrombus
prior to cardioversion. Transesophageal echocardiography showed
that the distal half of the LAA was indeed excluded with no
evidence of blood flow into the excluded cavity by Doppler imaging.
The proximal half of the appendage, however, was patent with
a large (1.3 cm
x 1.0 cm) thrombus located just above the suture
line (
Figure 1). The planned cardioversion was cancelled
and the patient was later discharged from the hospital on warfarin
without further complication.
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Figure 1 Transesophageal echocardiography of the left atrium (LA). Note the thrombus within the proximal left atrial appendage (long arrow) and the suture line from the ligation of the distal appendage (short arrows).
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Discussion
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Ligation of the LAA is occasionally performed during valvular
surgery to minimize risk of thrombus formation and potential
distal embolization. While there are no randomization, prospective
data to confirm that appendage exclusion decreases such risk,
there are retrospective data which suggest that it might.
3 It
is well documented, however, that surgical attempts to ligate
the appendage sometimes fail to achieve complete exclusion due
to disruption along the closure line.
1–4 Flow into an
area of stagnating blood may actually increase the risk of embolization.
1,2 This present case differs from prior reports of incomplete LAA
ligation in that there was no apparent disruption of the suture
line. In this case a ‘successful’ exclusion of the
appendage was achieved, but only for the distal half, thus leaving
the proximal half as a potential location for thrombus formation.
Indeed a thrombus did form in this proximal portion of the appendage,
as was clearly visualized by transesophageal echocardiography.
In two studies evaluating 58 and 50 patients, respectively, after LAA ligation, the incidence of incomplete closure was 10% and 36%.3,4 While the clinical impact of incomplete closure is unknown, some have proposed that the resultant flow into an area of stagnating blood may actually increase the risk of embolization.1,2 It has also been proposed that different surgical suturing techniques might be responsible for higher incidences of incomplete closure.3 When ligating the LAA with suturing from the endocardial surface, the surgeon generally takes shallow bites to avoid damage to the left circumflex artery. This present case demonstrates, however, that even with epicardial suturing, LAA ligation may be incomplete, and thrombus formation still possible. Further investigation would be necessary to evaluate the optimal technique for LAA ligation, as well as the clinical effectiveness of this procedure.
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References
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- Katz ES, Kronzon I. Incomplete ligation of the left atrial appendage: diagnosis by transesophageal echocardiography. Am J Noninvasive Cardiol (1992) 6:262–3.
- Rosenzweig BP, Katz E, Kort S, Schloss M, Kronzon I. Thromboembolus from a ligated left atrial appendage. J Am Soc Echocardiogr (2001) 14:396–8.[CrossRef][Web of Science][Medline]
- 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. J Am Coll Cardiol (2003) 42:1253–8.[Abstract/Free Full Text]
- Katz ES, Tsiamtsiouris T, Applebaum RF, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiographic study. J Am Coll Cardiol (2000) 36:468–71.[Abstract/Free Full Text]
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Abstract
Introduction