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Definition of Success after Epicardial Left Atrial Appendage Occlusion - Formation of Left Atrial Diverticulum and Remnant Stump.
Grzegorz Suwalski1, Robert Emery2, Leszek Gryszko1, Kamil Kaczejko1, Jakub Mroz1, Przemyslaw Szlanski1, Andrzej Skrobowski1.
1Military Institute of Medicine, Warsaw, Poland, 2Department of Cardiac Surgery St Joseph’s Hospital, Minnesota, MN, USA.

OBJECTIVE: Left atrial appendage (LAA) closure with use of epicardial occluders is emerging technique in stroke prevention in patients with atrial fibrillation (AF). Remnant LAA stump is a major success criterion and it is needed to elaborate its early method of assessment. Aim of the study was to assess early success rate of epicardial LAA closure and factors leading to remnant LAA stump formation with proposed echocardiographic method.
METHODS: Fifteen consecutive patients with persistent AF and coronary artery disease underwent surgical off-pump revascularization with concomitant left atrial ablation and LAA epicardial occlusion with use of either Tiger Paw System II® (Maquet) or AtriClip® (Atricure, Dayton, OH, USA). Before surgery start and after chest closure transoesophageal echocardiography was performed to assess LAA morphologic type and length, LAA orifice diameter, diameter of left atrial ridge and remnant LAA stump.
RESULTS: In 80% (12) of patients formation of left atrial diverticulum was observed and left atrial ridge formed its superior boundary. In 5 patients (33%) minimal remnant LAA stump was found but in none exceeding 1 cm (average length: 1,5 +/- 2,3 mm). In all patients blood flow in LAA cavity distally to occluder was excluded. In AtriClip group LAA remnant stump was observed in 3 cases (43%) and in Tiger Paw group in 2 patients (25%; p=0,6). There was no significant difference in LAA type, average diameter of left atrium, LAA orifice, LAA length, left atrial ridge and size of occluder used between patients with and without remnant LAA stump. Occurrence of remnant LAA stump correlated significantly with unfavorable anatomy (LAA orifice 5 mm; r=0,5774, p=0,02).
CONCLUSIONS: Early success of epicardial LAA occlusion is not dependent on anatomy of LAA and type of occluder used. Minimal remnant LAA stump not exceeding 1 cm in length and with no blood flow in LAA is observed in one third of the cases. Diverticulum should not be considered as part of remnant LAA stump since it is formed with intracardiac left atrial ridge.

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