Pii: S1010-7940(00)00419-x

Objectives: To prevent death from atrial ®brillation, a cardiac disease which kills by producing emboli. Atrial ®brillation causes about 25% of strokes and increases stroke rate by ®ve times. Over 90% of these embolic strokes are from clots originating in the left atrial appendage. This study addresses the surgical feasibility of removing the appendage to prevent future deaths in two subcategories of patients. (1) Prophylactic removal during open-heart surgery to study its safety. Theoretically, as these patients age and some develop atrial ®brillation, protection from embolic strokes would already be present. (2) Therapeutic removal in chronic atrial ®brillation patients by means of a thorascopic approach. Its technical feasibility is demonstrated. Its actual stroke prevention potential awaits large studies. Methods: Appendectomy has been evaluated three ways. (1) Experimentally, thorascopic appendage removal was performed on 20 goats with endoscopic approach. Late studies showed a cleanly healed atrial closure after stapling, and no puckering of tissue as seen with the purse-string approach. (2) Safety of human appendectomy was demonstrated in 437 patients (1995±1997). Routine appendectomy was performed during open-heart surgery. Forty-three appendages were stapled, 391 sutured off. (3) Thorascopic appendectomy in seven patients with chronic atrial ®brillation has been successfully accomplished as an isolated surgical procedure. Stapling or suture closure provides a much cleaner, non-puckered suture line than a purse string. Results: In prophylactic removal, no acute bleeding occurred. No late problems have been identi®ed. Endoscopic removal of the appendage has been successful in seven atrial ®brillation patients. Conclusions: The left atrial appendage is a lethal source of emboli in atrial ®brillation patients. As patients age and often develop atrial ®brillation, prophylactic appendage removal whenever the chest is open is suggested as a method to prevent future strokes. In chronic atrial ®brillation patients, appendectomy can be done with a mini-thorascopic approach. Further studies are planned to demonstrate the effectiveness of appendectomy in preventing strokes in the chronic ®brillating patients. q 2000 Elsevier Science B.V. All rights reserved.