1. Maurizio Gentile
Centro Cuore Morgagni - Pedara
CUORE E TECNOLOGIE:
EVOLUZIONE DELLA
CARDIOLOGIA
INTERVENTISTICA
CHIUSURA DELL’AURICOLA

2. E’ ben noto il ruolo dell’auricola sn nel tromboembolismo
della malattia mitralica e della fibrillazione atriale (57-90%)
La chiusura dell’auricola sn: il ruolo del chirurgo

3. La chiusura chirurgica dell’auricola sn è una tecnica
nota 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
La chiusura dell’auricola sn: il ruolo del chirurgo

4. 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.
La chiusura dell’auricola sn: il ruolo del chirurgo

5. J Am Coll Cardiol, 2006
ACC/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..….
La chiusura dell’auricola sn: il ruolo del chirurgo

6. -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
La chiusura dell’auricola sn: il ruolo del chirurgo

7. 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
La chiusura dell’auricola sn: il ruolo del chirurgo

8. 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
La chiusura dell’auricola sn: il ruolo del chirurgo

9. Number of left atrial appendage publications in various periods
from 1948 to 2011
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter Experiences
Subhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011
La chiusura dell’auricola sn: il ruolo del chirurgo
Nonostante il consenso sulla
chiusura, è meno chiaro
quale sia la miglior tecnica.
La letteratura chirurgica
consiste in serie di pz con
pregressa chiusura e segni
clinici successivi
(valutazione ETE)

10. 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.
La chiusura dell’auricola sn: il ruolo del chirurgo

11. 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
La chiusura dell’auricola sn: il ruolo del chirurgo

12. Tecniche chirurgiche di chiusura dell’auricola sn
Legatura-Sutura epicardica
(a cuore chiuso)
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter Experiences
Subhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011
La chiusura dell’auricola sn: il ruolo del chirurgo

13. Tecniche chirurgiche di chiusura dell’auricola sn
Sutura endocardica con sopragitto in CEC
(paz valvolari)
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter Experiences
Subhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011
La chiusura dell’auricola sn: il ruolo del chirurgo

14. Tecniche chirurgiche di chiusura dell’auricola sn
Escissione-sutura epicardica con stapling device
J Thorac Cardiovasc Surg 2005
Stapled excision of the left atrial appendage A. Marc Gillinov, MD*….. Delos M. Cosgrove, III, MD
Dept of Thor and Cardiovasc Surg, Cleveland, Ohio
La chiusura dell’auricola sn: il ruolo del chirurgo

15. Tecniche chirurgiche di chiusura dell’auricola sn
Amputazione-sutura epicardica
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter Experiences
Subhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011
La chiusura dell’auricola sn: il ruolo del chirurgo

16. Journal of the American College of Cardiology, 2008
Success of Surgical Left Atrial Appendage Closure
Assessment 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 %).
La chiusura dell’auricola sn: il ruolo del chirurgo

17. 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%).
La chiusura dell’auricola sn: il ruolo del chirurgo

18. Tecniche chirurgiche di chiusura dell’auricola sn
Clip epicardica (accesso standard o mini-inv)
AtriClip™ Gillinov-Cosgrove LAA Exclusion System, Standard
La chiusura dell’auricola sn: il ruolo del chirurgo

19. 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)
La chiusura dell’auricola sn: il ruolo del chirurgo

20. 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
Conclusions: safe and atraumatic exclusion of the
left atrial appendage can be performed during open
cardiac surgery with the AtriClip device with
greater than 95% success and appears to be
durable in the short term by imaging.
La chiusura dell’auricola sn: il ruolo del chirurgo

21. Intraoperative TEE demonstrating
(A) patent LAA before AtriClip device placement and
(B) echocardiographic evidence of LAA exclusion after clip placement.
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
La chiusura dell’auricola sn: il ruolo del chirurgo

22. CT scan (A) preoperatively demonstrating patent LAA lumen and
(B) postoperatively at 3 months after AtriClip device
insertion demonstrating endovascular exclusion of the LAA.
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
La chiusura dell’auricola sn: il ruolo del chirurgo

23. 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
La chiusura dell’auricola sn: il ruolo del chirurgo

24. Tecniche chirurgiche di chiusura dell’auricola sn
La chiusura dell’auricola sn: il ruolo del chirurgo
•Tecniche diverse endo - epicardiche
(chiusura incompleta – residuo)
• Possibile su qualunque anatomia
• Accesso mini-invasivo
• Non necessità di TAO

25. • 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 I
indicazioni

26. • 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 II
tecnica

27. 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