Thoracoscopic obliteration of the left atrial appendage: Potential for stroke reduction?

Background. In a review of all relevant articles describing the site of left atrial thrombus in patients with atrial fibrillation, the thrombus was localized to the left atrial appendage in 43% of patients with rheumatic heart disease and in 91% of patients with nonrheumatic atrial fibrillation. This study was designed to test the feasibility of thoracoscopic obliteration of the left atrial appendage as a means of reducing thromboembolic stroke. Methods. Thoracoscopic obliteration of the left atrial appendage was undertaken in 10 dogs, 5 with staples and 5 with an endoloop. Obliteration also was attempted in 8 fresh human cadavers. Results. In all dogs, the appendage was rapidly obliterated (21.3 +/- 7.6 minutes) and confirmed at euthanasia at 11 weeks. In 3 cadavers, anatomic and disease factors prevented visualization of the left atrial appendage; in 1 the appendage tore, and in the remainder the appendage was obliterated. Conclusions. Obliteration of the left atrial appendage is feasible and may be considered as an additional surgical procedure to reduce stroke. The group of patients in whom it offers the greatest potential are those with atrial fibrillation deemed ineligible for warfarin, those without atrial thrombus and with a free pericardial and pleural space.