Choice of venous cannulation for bypass during repair of traumatic rupture of the aorta

BACKGROUND: Choices for venous cannulation for left heart bypass, to assist repair of traumatic rupture of the thoracic aorta, are between the left atrial appendage and pulmonary veins. METHODS: A retrospective chart review was performed of patients who underwent operative repair of ruptured aorta. RESULTS: Over a 15-year period between March 1985 and February 2000, 133 patients were admitted to a level I trauma center with aortic rupture. Of the 50 procedures performed with left heart bypass, the left atrial appendage was cannulated in 19 and pulmonary veins in 31 (four superior, 27 inferior). Complications occurred in 7 of the 19 patients who underwent venous cannulation via the atrial appendage (two ventricular fibrillation, three atrial fibrillation, one pericardial effusion leading to tamponade, and one phrenic nerve injury). Complications occurred in 2 patients who underwent cannulation via pulmonary vein (one atrial fibrillation, one pericardial effusion requiring tapping) (p = 0.02). CONCLUSIONS: Cannulation via the pulmonary veins is associated with a decrease in complication rates compared with cannulation of the atrial appendage.     

Cannulation through the left atrial appendage facilitates Mustard's operation for transposition of the great arteries

In a patient with transposition of the great vessels and juxtaposition of the atrial appendages, improved exposure for placement of Mustard's interatrial baffle was gained by inserting the superior vena caval catheter into the juxtaposed right atrial appendage. In 3 subsequent patients with normal atrial appendages the left atrial appendage was used for introduction of this catheter, which was then guided across the atrial septal defect into the superior vena cava. Advantages of this method over conventional cannulation are discussed.     

Surgical techniques for the implantation of heterotopic prosthetic ventricles

Mechanical support of the failing heart is becoming an increasingly useful tool for bridging to cardiac transplantation and for recovery of the natural heart. Several options exist for cannulation sites during the implantation of the heterotopic prosthetic ventricles. These options include the left atrial appendage, the left ventricular apex, the interatrial groove, and the left atrial roof. The indications, contraindications, advantages, disadvantages, and surgical technique for each option are described. Operation of the drive console and postoperative care are also discussed.     

Effect of right atrial appendectomy on the release of atrial natriuretic hormone.

Atrial natriuretic hormone is released from the right atrial appendage in response to atrial distention. During cardiac operations the right atrial appendage is usually partially removed or ligated for venous cannulation. To evaluate the effect of right atrial appendectomy on the release of atrial natriuretic hormone and its natriuretic and diuretic responses, we prospectively randomized into two groups 23 patients undergoing elective coronary artery bypass operations. There were 16 male and 7 female patients with a mean age of 62 +/- 7 years. Group A (n = 11) had the right atrial appendage removed, and group B (n = 12) had the right atrial appendage preserved and venous cannulation done lateral to the appendage. The two groups were comparable for sexual distribution, age, number of grafts, and extracorporeal bypass time. All patients had normal left ventricular and renal functions, and they did not receive any diuretics during the study period. The patients were studied both preoperatively and postoperatively whereby the atrial natriuretic hormone serum levels, urine volume per minute, fractional excretion of sodium, amount of sodium excreted, and central venous pressure were measured before and after volume expansion with 5% albumin, 7.5 ml/kg. There was no statistical difference in these parameters preoperatively. In the postoperative period, however, group B patients had higher atrial natriuretic hormone levels after volume expansion than group A patients (376 +/- 84 versus 184 +/- 31 pg/ml; p less than 0.05), higher urine volume per minute (4.4 +/- 1.0 versus 2.0 +/- 0.4 ml/min; p less than 0.05), higher fractional excretion of sodium (2.30 +/- 0.66 versus 0.64 +/- 0.19; p less than 0.02), and higher amount of sodium excreted (511.1 +/- 150.9 versus 83.9 +/- 22.8 mmol/min; p less than 0.02). The central venous pressure was similar both before (9 +/- 1 versus 9 +/- 1 mm Hg) and after (16 +/- 1 versus 15 +/- 1 mm Hg) volume expansion in both groups. We conclude that preserving the right atrial appendage during cardiac operations significantly increased the release of atrial natriuretic hormone, resulting in increased urinary sodium excretion and better diuresis in the postoperative period.     

改良Mini-Maze手术患者左心耳组织PITX2及KCNQ1蛋白表达特点分析及其临床相关性分析

目的 通过检测改良Mini-Maze手术心房颤动(房颤)患者左心耳组织PITX2及KCNQ1蛋白表达水平,结合临床数据对不同类型房颤的临床危险因素进行分析.方法 收集2017年2月至2018年8月因房颤于本中心行手术患者共59例的左心耳组织,其中58例行改良Mini-Maze手术,即双侧微创切口下行双极射频消融术、双侧...     

Bilateral endoscopic technique for left atrial appendectomy and robot-assisted mitral valve repair

We report a bilateral thoracoscopic technique in which robot-assisted mitral valve repair was achieved concomitantly with stapler division of the large left atrial appendage. The patient was a 65-year-old male with severe mitral regurgitation, paroxysmal atrial fibrillation and a large-sized atrial appendage. Closure of the appendage was completed off-pump using a left thoracoscopic stapler-division technique previous to right thoracoscopic robot-assisted mitral valve repair and cryoablation. Complete closure of the appendage was confirmed in thoracoscopic views. The bilateral thoracoscopic technique could be preferable for the minimally invasive treatment of mitral valvular disease and concomitant large-sized atrial appendage management.     

Left atrial appendage occlusion device-related thrombus: a case report and review of the literature

A 75-year-old male with persistent atrial fibrillation underwent implantation of a left atrial occlusion device. After 6?weeks, a scheduled trans-esophageal echocardiogram showed a 1.1-cm?×?1.1-cm mass within the occluded left atrial appendage, suspected to be thrombus. He was continued on warfarin for an additional 6?weeks and a repeat trans-esophageal echocardiogram showed obliteration of the left atrial appendage. This report describes an uncommon observation detected at scheduled follow up by trans-esophageal echocardiogram, which sheds some light on the mechanism by which this device ??matures?? after it is implanted inside the left atrial appendage.     

Autosynchronized systolic unloading during left ventricular assist with a centrifugal pump

OBJECTIVES: The purpose of this study was to investigate how the inflow cannulation site of the left ventricular assist system with a centrifugal pump would influence cardiac function on failing heart models. METHODS: In 10 sheep, a left ventricular assist system was instituted by an outflow cannula in the descending aorta, two inflow cannulas in the left atrium and the left ventricle, and connecting those cannulas to a magnetically suspended centrifugal pump. A conductance catheter and a tipped micromanometer for monitoring the pressure-volume loop were also inserted into the left ventricle. Myocardial oxygen consumption was directly measured. Heart failure was induced by injection of microspheres into the left main coronary artery. The assist rate was varied from 0% to 100% at each inflow cannulation site. RESULTS: The pump flow with left ventricular cannulation increased during the systolic phase and decreased during the diastolic phase, whereas it was constant with left atrial cannulation. Ejection fraction with left atrial cannulation decreased as the assist rate increased, whereas that with left ventricular cannulation was maintained up to 75% assist. The external work with left atrial cannulation decreased gradually as the assist rate increased, whereas the external work with left ventricular cannulation did not decrease until the assist rate reached 75%. The myocardial oxygen consumption in both cannulations decreased proportionally as the assist rate increased; they were significantly less with left ventricular cannulation at the 100% assist rate than with left atrial cannulation. CONCLUSION: Left ventricular cannulation during left ventricular assistance maintains ejection fraction and effectively reduces oxygen consumption.     

Assessing the immediate and sustained effectiveness of circular epicardial surgical ligation of the left atrial appendage

Abstract Background/Aim: Obliterating the left atrial appendage from systemic circulation in patients with atrial fibrillation has been proposed to reduce thromboembolic events. The goal of this study was to assess the effectiveness of a circular method of epicardial surgical ligation in obliterating the left atrial appendage and maintaining sustained exclusion. Methods: Patients with permanent atrial fibrillation and an indication for elective cardiac surgery were enrolled. All patients underwent preoperative cardiac gated computerized tomography (CT) and transesophageal echocardiography (TEE). During the cardiac procedure circular ligation of the appendage was performed. Results: Twelve patients, mean (SD) age 65 (12) years completed the study. Intraoperative TEE demonstrated all patients (12/12) had complete postligation occlusion of the left atrial appendage. At three‐month follow‐up, cardiac gated CT demonstrated that 75% (9/12) of the patients had communication of contrast dye from the left atrial appendage to body of left atrium. Left atrial appendage orifice area and volume were reduced from mean (SD) (5.5 cm²[1.8] to 0.5 cm²[0.4] p = 0.002) and (14.0 cm³[8.3] to 2.7 cm³[1.3] p = .005) postligation, respectively. No clinically significant thromboembolic events were reported. Conclusions: Epicardial suture ligation of the left atrial appendage resulted in successful intra‐operative exclusion on TEE; however, a significant portion of patient's demonstrated communication of contrast on CT. This is suggestive of incomplete long‐term exclusion. The clinical significance of reduction in left atrial appendage orifice area and volume with a persistent communication requires further study.     

Mitral valve replacement through a giant left atrial appendage

We report a rare case of a 45-year-old male with a giant left atrial appendage (13x10 cm in size) and chronic massive regurgitation at the mitral valve. Massive dilatation was compressing most of the left lower lobe and the large size of the appendage was pushing the mediastinum to the right. Therefore under median sternotomy, the mitral valve was clearly accessible and chordal sparing mitral valve replacement with left atrial plication was successfully performed through the giant left atrial appendage.     

Staple closure of the left atrial appendage

Closure of the fibrillating left atrial appendage has been recommended during mitral valve repair or replacement to prevent systemic emboli postoperatively. Closure of the left atrial appendage has been accomplished in the past by direct intra-atrial suture or by external ligation. The authors have used the TA-55 automatic stapler in 40 patients to close the left atrial appendage during mitral valve surgery. In all patients the closure was effected successfully at the first attempt without complication.     

Robotic-assisted left atrial ligation for stroke reduction in chronic atrial fibrillation: a case report

Patients with atrial fibrillation are at significant risk for sustaining a thromboembolic stroke. More than 90% of thromboemboli form in the left atrial appendage. Ligation of the left atrial appendage to reduce the risk of stroke is often performed in connection with other cardiac surgical procedures. As a stand-alone procedure, however, left atrial ligation has generally been deemed too invasive and has gained little support as an alternative therapeutic option. We report a case of port-access robotic-assisted left atrial ligation as a stand-alone procedure in a patient with chronic atrial fibrillation in whom anticoagulation was a contraindication. To our knowledge, this is the first reported case of stand-alone robotic-assisted left atrial ligation in the literature.     

Left atrial appendage perforation with Watchman device implantation: Strategies for surgical repair

Percutaneous occlusion of the left atrial appendage is increasingly being used as an alternative for stroke prevention in patients with non‐valvular atrial fibrillation at high risk of complications from long term anticoagulation. We describe a case of left atrial appendage perforation during Watchman device implantation requiring emergency repair of the left atrium using sternotomy and cardiopulmonary bypass. Technical considerations for surgical decision making are discussed; in hemodynamically unstable patients as well as those at high risk for embolization.     

Congenital intrapericardial left atrial appendage aneurysm

Congenital true aneurysms of left atrial appendage are very rare. Abnormal cardiac silhouette on the chest roentgenograph is usually an important clue for the diagnosis. They are commonly associated with supraventricular arrhythmias and life-threatening systemic embolization. We report here the surgically-corrected case of a patient with congenital left atrial appendage aneurysm.     

Mitral stenosis with free-floating left atrial thrombus and recurrent systemic embolisation. A case report

A 64-year-old white woman with moderately severe rheumatic mitral stenosis complicated by atrial fibrillation and recurrent systemic embolisation to the brain was found at operation to have a large 'free-floating' left atrial thrombus, as well as multiple left atrial appendage thrombi. These had not been detected by echocardiography. She also had significantly reduced left ventricular contractility on cine angiography, and right coronary artery atherosclerosis. She underwent successful mitral valve replacement and excision of the left atrial appendage.     

Partial left pericardial defect with herniation of the left atrial appendage

A case is reported of herniation of the left atrial appendage through a partial pericardial defect, probably congenital. The diagnosis was suggested by the history of chest pain and bulging of the middle segment of the left heart border on the plain chest film, without other signs. Angiography revealed a dilated left atrial appendage. An artificial left pneumothorax confirmed the presence of a pleuropericardial defect. The surgical procedure included excision of the appendage and closure of the defect.     

Ligation of the Left Atrial Appendage Using an Automatic Surgical Stapler

We investigated the use of an automatic surgical stapler for ligation of the atrial appendage in sheep, and then applied this technique in patients. Fourteen adult sheep underwent ligation of the left atrial appendage using a surgical stapler with a rotating head and either absorbable or stainless steel staples. In 4 sheep, killed after two hours, no hemorrhage or intraatrial thrombus was observed acutely. Ten sheep were allowed to recover for 90 to 100 days, twice the expected absorption time of absorbable staples. There was complete obliteration of the left atrial appendage without evidence of intraatrial thrombus or staple migration. The absorbable staples were completely reabsorbed. We subsequently used this technique in 5 patients undergoing mitral valve procedures. There were no complications, and adequate obliteration of the atrial appendage was achieved.     

Left atrial appendage aneurysm

Aneurysms of the left atrial appendage are exceedingly rare. Patients most commonly present with atrial tachyarrhythmias and thromboembolism. Resection of the aneurysm is usually curative. We present a case report of a 60-year-old female with a long-standing history of atrial arrhythmias found to have a large left atrial appendage aneurysm with additional bi-atrial enlargement and a family history of atrial arrhythmias. The patient was successfully treated with resection of the aneurysm and a Cox-Maze III procedure.     

Use of tissue welding technology to obliterate left atrial appendage--novel use of Ligasure

The left atrial appendage is one source of thromboemobolus. Complete occlusion of this appendage is required to sever communication with the left atrium; however, current ligation techniques can potentially leave residual communication. A novel technique of occluding the appendage has been developed using a bipolar device and radiofrequency energy. Twelve patients underwent an off-pump, epicardial Maze procedure using radiofrequency ablation. As an adjunct to the procedure, ligation of the left atrial appendage was completed using the LigaSure Xtd (Valleylab, Tyco Healthcare, Boulder, CO) with a modified application technique. Patients were followed to ensure sinus or paced rhythm. All twelve patients are in sinus or paced rhythm upon follow-up. Four patients required pacemakers for sick sinus syndrome. To date there have been no incidents of strokes, thromboembolic events, postoperative bleeding or deaths in all patients. Complete occlusion of the left atrial appendage is necessary to eliminate communication, which is accomplished by this radiofrequency, bipolar device. Extensive studies are necessary to verify the efficacy of this novel occluding technique.     

Cardiac Hemangioma of the Left Atrial Appendag: A Case Report and Discussion

Abstract   Cardiac hemangioma is an extremely rare, benign vascular tumor of the heart. In contrast to myxoma, hemangioma rarely involves left atrial tissue in adults and little information about the tumor is available. We encountered a 65-year-old woman with a left atrial hemangioma arising in the appendage and growing like an extracardiac mass. The tumor was removed from the left atrium with all the left appendage under cardiopulmonary bypass. Histopathological examination revealed that it was a cavernous-type hemangioma. Among the five described cases, this case was the only one in which the tumor arose from the appendage and grew into the pericardial cavity with resultant paroxystic atrial fibrillation.