[HSF] Routine closure of the left atrial appendage?

[erdinç naseri]

Ani,
 1.LAA is the site of formation of thrombus nidus in patients with LA clots .This is the source of cardiac emboli in patients with otherwise normal LV endocardium and cavity.If ligated free of complication there will be a prophylaxy against this type of CVA.I ligate it externally with silk suture and to date there hasn't be a catastrophic bleeding( hope this will be so forever)
2.AF surgery is not in much use here so no anecdotal catastrophic events known by me.
3.Though there are not much medical suits here  ,still we get written consent of the patient for all the procedures.
4.No statistically valuable data .
erdinc> From: anianyanwu at hotmail.com> To: openheart-l at lists.hsforum.com> Subject: RE: [HSF] Routine closure of the left atrial appendage?> Date: Thu, 19 Jul 2007 10:44:15 +0000> > But Erdinc,> > What is the evidence (provide references if you) can that> > 1. LAA clot is the cause of embolic strokes seen with AF> 2. Ligation of this structure eliminates or reduces the risk.> 3. A patent LA appendage is a cause of stroke after cardiac surgery> 4. Obliteration of the LAA reduces stroke risk after cardiac surgery> 5. Obliteration of the LAA is not without risk.> 6. An LAA which has been patent and clot free for decades (even in a patient with long history of AF) will suddenly develop clot within because you did a heart operation.> > While I await the data, In response to your statement that you would rather have a patient neurologically intact, I would rather have one alive with a theoretical risk of embolic stroke than one who haemorrhages to death from this easy (or timorous!) inconsequential procedure as many might believe. BTW ask around about deaths after mini-invasive AF surgery and you will find stories of disasters from interfering with this structure. A rep told me of three such deaths in young patients.> > Again that we can cut bits and pieces out the body, even if without risk for the extraordinarily skilled surgeons amongst us, doesn't mean we should - these bits and pieces belong to a human being's body and we should respect that. BTW (and this goes to Hal's land of medicine by lawyers) if a patient sued you for wrongfully performing an operation and stealing tissue from his body (by excising his LAA during a routnine OPCAB), I doubt you could defend that in any court of legal or medical practice, but then again you may have data to answer my questions which I eagerly await.> > > > > Ani> > > > > From: enaseri at hotmail.com.tr> To: openheart-l at lists.hsforum.com> Subject: RE: [HSF] Routine closure of the left atrial appendage?> Date: Thu, 19 Jul 2007 06:28:05 +0000> > > Ani,> I would prefer to have a neurologicaly intact patient with loss of some unknown endocrine fx rather than a completely normal endocrinologic patient with a major stroke.( and I think the patient would also vote in favor of the 1.st choice.> erdinc> From: anianyanwu at hotmail.com> To: openheart-l at lists.hsforum.com> Subject: RE: [HSF] Routine closure of the left atrial appendage?> Date: Wed, 18 Jul 2007 20:52:15 +0000> > A few years ago as a resident at Harefield I was once questioned by Yacoub as to why I was virtually obliterating the RA appengae while repairing a cannulation site. "The appendage is a delicate organ" he said .."it must be preserved at all costs - it is there for a reason". The next question which followed was "what are the endocrine functions of the atrial appendage?". Indeed if you watched yacoub cannulate he barely ever touched or instrumented the appendage and always left the patient with this structure anatomically intact. > > This stuck with me, not because of relevance or otherwise of the appendage but the realization that human bodies are complex and all parts have/had a part to play. We as surgeons should therefore not mutilate the human body at will and just cut and tie things because we > can. Cut and do only what is necessary and leave others well alone, for we do not always know why they are there.> > Why don't you set up a randomized trial? If you demonstrate benefit and minimal risk to routine LAA exclusion then I am sure many will consider it. On the contrary if you find no benefit or harm then maybe Yacoub was right - the LA appendage is there for a reason and best left untouched.> > Ani> > > > > > > Date: Wed, 18 Jul 2007 12:16:23 -0500> From: mwertheimer at mahealthcare.com> To: OpenHeart-L at lists.hsforum.com> CC: > Subject: [HSF] Routine closure of the left atrial appendage?> > Given the substantial incidence of atrial fibrillation following cardiac> surgery, and the frequent need to place many of these patients on> Coumadin anticoagulation to reduce the risks of embolic stroke, has> anyone gone to routinely closing off the left atrial appendage with all> cardiac surgeries? It can be easily done with the use of the noncutting> endo- stapling device.> > _> ______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> _________________________________________________________________> The next generation of MSN Hotmail has arrived - Windows Live Hotmail> http://www.newhotmail.co.uk_______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ------------------> -----------------------> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> _________________________________________________________________> Try Live.com - your fast, personalised homepage with all the things you care about in one place.> http://www.live.com/?mkt=en-gb _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------