CUORE E TECNOLOGIE: EVOLUZIONE DELLA CARDIOLOGIA INTERVENTISTICA CHIUSURA DELL’AURICOLA

Maurizio GentileCentro Cuore Morgagni - Pedara

CUORE E TECNOLOGIE: EVOLUZIONE DELLA

CARDIOLOGIA INTERVENTISTICA

CHIUSURA DELL’AURICOLA

E’ ben noto il ruolo dell’auricola sn nel tromboembolismodella malattia mitralica e della fibrillazione atriale (57-90%)

La chiusura dell’auricola sn: il ruolo del chirurgo

La chiusura chirurgica dell’auricola sn è una tecnicanota da molti anni, eseguita soprattutto nei pazienti mitralici sottoposti ad intervento cardiochirurgico.

Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.Blackshear JL, Odell JA. Ann Thorac Surg 1996.

Madden JL. Resection of left auricolar appendix: a prophylaxis for recurrent arterial emboli. JAMA 1949


Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis:

a transesophageal echocardiographic study.García-Fernández MA, ……, Moreno M, Silva J. , Madrid, Spain. J Am Coll Cardiol. 2003

CONCLUSIONS: LAA ligation during surgery of mitral valve replacement, performed in a high-risk population, is consistent with a reduction of the risk of late embolism and supports this technique.


http://www.ncbi.nlm.nih.gov/pubmed?term=%22Garc%C3%ADa-Fern%C3%A1ndez%20MA%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Garc%C3%ADa-Fern%C3%A1ndez%20MA%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Moreno%20M%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Silva%20J%22%5BAuthor%5D

J Am Coll Cardiol, 2006ACC/AHA 2006 Guidelines for the Management

of Patients With Valvular Heart Disease

Chirurgia conservativa della stenosi mitralica

..…amputation of the left atrial appendage is recommended to reduce the likelihood of postoperative thromboembolic events..….


-Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiographic study. J Am Coll Cardiol. 2000 Katz ES, ……Kronzon I-Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol. 2008 Kanderian AS, Gillinov AM-Mmcts.2010 Sacha P. Salzberg, Management of the left atrial appendage

Attualmente viene eseguita di routine durante chirurgia cardiaca solo da alcuni gruppi:

- Per insufficiente attenzione sull’importanza - Per risultati incerti (tecniche imperfette

e traumatiche) - Funzione dell’auricola


Indicazioni più recenti

•A complemento di ablazione di FA•Trattamento isolato in pz in FA

• Calkins H… et al HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2007

• Di Biase L,…..et all. Left atrial appendage: an underrecognized trigger site of atrial fibrillation. Circulation 2010• Takahashi Y, Haissaguerre M. Disconnection of left atrial appendage for elimination of foci maintaining atrial fibrillation.J Cardiov Electroph 2005

• L’auricola sn rappresenta un trigger per insorgenza di FA e di tachicardie atriali e ricorrenza di FA dopo ablazione. • La chiusura dell’auricola permette l’isolamento elettrico dell’auricola


HRS/EHRA/ECAS (2007) Expert Consensus Statement on

Catheter and Surgical Ablation of Atrial Fibrillation:

Surgical AF Ablation Concomitant to Other Heart Operations

all patients with AF undergoing other cardiac surgery should be considered for AF ablation ………………..………….. When it can be safely performed, complete occlusion of the LA appendage should be considered


Number of left atrial appendage publications in various periodsfrom 1948 to 2011

Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter ExperiencesSubhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011


Nonostante il consenso sulla chiusura, è meno chiaroquale sia la miglior tecnica.

La letteratura chirurgica consiste in serie di pz con pregressa chiusura e segniclinici successivi(valutazione ETE)

Cardiology, 2005.

Surgical closure of the left atrial appendage – a beneficial procedure?Schneider B, Stollberger C, Sievers HH.

Klinik fur Kardiologie, Sana Kliniken Lubeck, Deutchland.

CONCLUSION: Surgical LAA closure was incomplete in most patients, resulting in blood stagnation and an increased likelihood of clot formation. Incomplete surgical LAA closure, therefore, may promote rather than reduce the risk of stroke.


http://www.ncbi.nlm.nih.gov/pubmed?term=%22Schneider%20B%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Stollberger%20C%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Stollberger%20C%22%5BAuthor%5D

L’anatomia dell’auricola è molto variabile

Three-dimensional anatomy of the left atrium by magnetic resonance angiography: implications for catheter ablation for atrial fibrillation Mansour M, …… Ruskin JN. J Cardiovasc Electrophysiol 2006

Tecniche chirurgiche di chiusura dell’auricola sn



Legatura-Sutura epicardica (a cuore chiuso)




Sutura endocardica con sopragitto in CEC (paz valvolari)




Escissione-sutura epicardica con stapling device

J Thorac Cardiovasc Surg 2005Stapled excision of the left atrial appendage A. Marc Gillinov, MD*….. Delos M. Cosgrove, III, MD Dept of Thor and Cardiovasc Surg, Cleveland, Ohio



Amputazione-sutura epicardica



Journal of the American College of Cardiology, 2008

Success of Surgical Left Atrial Appendage ClosureAssessment by Transesophageal Echocardiography

Anne S. Kanderian, MD,* A. Marc Gillinov, Eugene Blackstone, MD,Cleveland, Ohio

Conclusions:Of the various techniques (excision or exclusion by sutures or stapling), excision appears to be the most successful (73 %).


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

Jeff S Healey,……….Stuart J Connolly - American Heart Journal, 2005

CONCLUSIONS: LAA occlusion ( stapler or epicardial suture)at the time of CABG (77 pts) …The rate of complete occlusion improves…… with the use of a stapling device (72% vs 45%). A large trial is needed to determine if LAA occlusion prevents stroke (2,6% vs 5,6%).



Clip epicardica (accesso standard o mini-inv)

AtriClip™ Gillinov-Cosgrove LAA Exclusion System, Standard


J of Thor and Cardiovasc Surgery, Nov 2011

Exclusion of the left atrial appendage with a novel device: Early results of a multicenter trial

Gorav Ailawadi, MD,…..Ralph J. Damiano, Jr, MD and Michael J. Mack, MDg

Concomitant cardiac operations performed in the EXCLUDE study

Surgical procedure Total % (n) (N ¼ 71)

CABG 77.5% (55)Mitral valve 23.9% (17) Repair 16.9% (12) Replacement 7.0% (5)Tricuspid valve 5.6% (4) Repair 5.6% (4)Aortic valve 40.8% (29) Replacement 40.8% (29)ASD/PFO closure 0.0% (0)Surgical (ablation or cut-and sew) Maze procedure 35.2% (25)





Conclusions: safe and atraumatic exclusion of the left atrial appendage can be performed during opencardiac surgery with the AtriClip device with greater than 95% success and appears to be durable in the short term by imaging.


Intraoperative TEE demonstrating (A) patent LAA before AtriClip device placement and(B) echocardiographic evidence of LAA exclusion after clip placement.





CT scan (A) preoperatively demonstrating patent LAA lumen and (B) postoperatively at 3 months after AtriClip deviceinsertion demonstrating endovascular exclusion of the LAA.





Thoracoscopic appendage exclusion with an atriclip device as a solo treatment for

focal atrial tachycardia.Stefano Benussi, ……… and Paolo Della Bella

Circulation (2011)

Appendage clip implantation as a solo procedure




•Tecniche diverse endo - epicardiche (chiusura incompleta – residuo)

• Possibile su qualunque anatomia

• Accesso mini-invasivo

• Non necessità di TAO

• L’occlusione dell’auricola sn è un punto essenziale nella prevenzione dello Stroke nei pazienti in FA

• La chiusura dell’auricola sn va considerata:

-nei pz cardiochirurgici (FA cronica-megaatrio)

-nei pz sottoposti ad ablazione chirurgica concomitante a chir cardiaca (FA parossistica?)

CONCLUSIONI Iindicazioni

• Il successo della chiusura dell’auricola dipende dalla tecnica (evoluzione delle tecniche)

• Le tecniche chirurgiche epicardiche sembrano le più dirette, efficaci e sicure (escissione-sutura, clip)

•La completa chiusura dell’auricola va documentata (rischio chiusura incompleta)

CONCLUSIONI IItecnica

CONCLUSIONI III

Le tecniche chirurgiche mini-invasive ed i nuovi devices (chirurgici e percutanei) possono portare a nuove indicazioni di chiusura dell’auricola

-chirurgia della FA isolata -”sole therapy” (controindicazione a percutane e a

anticoagulazione orale)

-interventi ibridi (chirurgo - elettrofisiologo)

Studi randomizzati percutanea vs chirurgia

CUORE E TECNOLOGIE: EVOLUZIONE DELLA CARDIOLOGIA INTERVENTISTICA CHIUSURA DELL’AURICOLA

Health & Medicine

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