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J Thorac Cardiovasc Surg 2007;134:550
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

Keiji Kamohara, MDa, Zoran B. Popovic, MD, PhDb, A. Marc Gillinov, MDc, Kiyotaka Fukamachi, MD, PhDa

a Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
b Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
c Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio

We appreciate the response of Drs Stöllberger, Schneider, and Finsterer to our work1Go and thank them for their comments. Here are our responses to their specific questions:

1 The left atrial appendage (LAA) area was not included when measuring the left atrial (LA) area. Slight changes in LA area and volume measurements might be expected due to the effect of the LA body shape change caused by occlusion of the LAA orifice. However, we have not detected any statistically significant decreases in the LA area or volume after LAA exclusion.
2 Although we did not measure the size of the LAA in this series, we did measure it in a more recent series of 16 dogs. The width and thickness of the LAA orifice were 27.1 ± 4.8 mm (mean ± standard deviation) and 12.2 ± 4.3 mm, respectively. As indicated by relatively small standard deviations, there is not a great variation in the LAA size in dogs.
3 Although we did not measure natriuretic peptide levels in this series, we did measure atrial natriuretic peptide and B-type natriuretic peptide levels in a more recent series. There were no significant changes in atrial natriuretic peptide level (32 ± 20 pg/mL at baseline and 41 ± 34 pg/mL after 30 days, P = .60) or B-type natriuretic peptide level (always <5 pg/mL). We did not observe any weight gain caused by fluid retention.
4 The investigated dogs were all killed on the day of the terminal study. During our follow-up period, we did not observe any significant decrease in stroke volume.
5 The effects of LAA occlusion on hemodynamics in patients with heart disease and in atrial fibrillation have to be carefully investigated in the future.
We disagree with their conclusion that hemodynamically LAA occlusion might even do harm and should therefore not be performed in patients with atrial fibrillation. There is no solid evidence to suggest that exclusion of the LAA in patients with atrial fibrillation does harm. In fact, there is good evidence suggestive to the contrary2,3Go; much of this has been gathered from patients undergoing mitral valve surgery or surgical ablation. However, it is also clear that surgical LAA ligation with current techniques and technology is sometimes incomplete. Such incomplete ligation might be responsible for an increased risk of thromboembolic events after attempted ligation.4Go Our focus is on the development of a method for reliable, complete, and simple occlusion of the LAA. With such an approach, we will have the ability to study the clinical effects of LAA exclusion. At this time, we believe that such effects have not been fully elucidated.

References

  1. Kamohara K, Popovic ZB, Daimon DM, Martin M, Ootaki Y, Akiyama M, et al. Impact of left atrial appendage exclusion on left atrial function. J Thorac Cardiovasc Surg 2007;130:1639-1644.
  2. Johnson WD, Ganjoo AK, Stone CD, Srivyas RC, Howard M. The left atrial appendage: our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg 2000;17:718-722.[Abstract/Free Full Text]
  3. García-Fernández MA, Pérez-David E, Quiles J, Peralta J, García-Rojas I, Bermejo J, et al. Role of the left atrial appendage obliteration in stroke reduction in patients with mitral valve prolapse: a transesophageal echocardiographic study. J Am Coll Cardiol 2003;42:1253-1258.[Abstract/Free Full Text]
  4. Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiographic study. J Am Coll Cardiol 2000;36:468-471.[Abstract/Free Full Text]

Related Article

Leave the left atrial appendage untouched for stroke prevention!
Claudia Stöllberger, Birke Schneider, and Josef Finsterer
J. Thorac. Cardiovasc. Surg. 2007 134: 549-550. [Extract] [Full Text] [PDF]




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