A Comparative Study Between Different Surgical Techniques For Left Atrial Exclusion in Patients Undergoing Concomitant Cardiac Surgery

Objectives: To find out the most successful surgical technique to obliterate left atrial appendage (LAA) in atrial fibrillation (AF) patients who had undergone concomitant cardiac surgery. Background: About 10%-65% of patients develop AF following cardiac surgery [Rho 2009; Mathew 2004; Maesen 2012]. Cerebral cardio-embolic stroke remains the most serious complication in AF patients. LAA is the main anatomical source for thromboembolic events. The use of oral anticoagulants (OAG) is considered to be an effective method for reduction of thromboembolic complications [Johnson 2000]. The use of oral anticoagulants is faced by two important facts which are the therapy duration is still unknown [Kirchhof 2017] and importantly that between 30-50% of patients are not candidates for oral anticoagulants due to the high bleeding risk or other contraindications [Johnson 2000; Kirchhof 2017; Kirchhof 2014]. In such patients, LAA obliteration would be an optimal alternative technique as it will reduce the stroke risk by 50% [Go 2014]. Several surgical techniques with variable degrees of success rates have been used. It still is unclear which surgical technique is optimum to achieve a successful obliteration of the LAA and a considerable reduction of the postoperative stroke events in AF patients. Patients and methods: A total of 100 patients have been subjected to surgical LAA exclusion from April 2017 to April 2019 in two different centers. All patients had postoperative transesophageal echo (TEE) examination to confirm the success of LAA occlusion. All patients included in our study suffered from AF at the time of surgery or in past history, which was confirmed by ECG examination in their previous medical files. A variety of surgical techniques to close the LAA have been utilized, including surgical excision by means of scissors, patch exclusion by means of an endocardial patch, suture exclusion and finally stapler exclusion. TEE examination 16 months postoperatively divided our patients into four groups as follows: successful LAA occlusion, Patent LAA, excluded LAA with persistent flow into LAA, and remnant LAA with a stump connection with LAA more than 1 cm. Results: Out of 100 patients, 30 patients (30%) underwent surgical LAA excision, 24 patients (24%) underwent surgical epicardial suture ligation, eight patients (8%) underwent patch exclusion using autologous pericardial patch, 33 patients (33%) underwent LAA internal orifice purse string suture obliteration, and five patients (5%) underwent stapler exclusion. Forty-two patients out of 100 (42%) showed successful LAA closure. The successful LAA occlusion occurred mostly in LAA excision patients 87%, 24% in LAA internal orifice purse string suture obliteration patients, 21% in epicardial suture ligation patients, and 37.5% in patch exclusion patients. The stapler exclusion was very disappointing as we did not record a single case out of the five patients who showed a successful LAA occlusion. Stroke events were recorded in all surgical techniques except the LAA excision technique. The stroke rate after two years follow up was zero in the surgical excision group, 49% in the suture exclusion group, 20% in the patch exclusion group, and 40% in stapler exclusion group. Conclusion: Surgical LAA excision is the most successful technique for LAA occlusion and represents a promising technique for the reduction of thromboembolic events in AF patients who undergo a concomitant cardiac surgery.

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A new method of left atrial appendage occlusion for the prevention of thromboembolic complications in patients with atrial fibrillation during coronary artery bypass grafting

Russian Journal of Cardiology ◽

10.15829/1560-4071-2020-3699 ◽

2020 ◽

Vol 25 (8) ◽

pp. 3699

Author(s):

Yu. Yu. Vecherskiy ◽

Yu. I. Bogdanov ◽

R. E. Batalov ◽

V. V. Zatolokin ◽

V. V. Saushkin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Coronary Artery ◽

Coronary Artery Bypass Grafting ◽

Left Atrial ◽

Left Atrial Appendage ◽

Artery Bypass ◽

Suture Technique ◽

Bypass Grafting ◽

Purse String Suture ◽

Purse String

Aim. To optimize the surgical technique for left atrial appendage (LAA) occlusion in patients with atrial fibrillation (AF) during coronary artery bypass grafting.Material and methods. The study included 60 patients with atrial fibrillation (AF). The patients were randomly divided into 2 groups. In the first group of patients, LAA was closed using the developed two-suture technique. In patients of the second group, a purse string suture was applied to the LAA. All patients underwent transesophageal echocardiography (TEE) before surgery to rule out the presence of intracardiac blood clots. To assess the effectiveness of the method in the postoperative period, TEE was performed.Results. According to postoperative TEE, one case of LAA recanalization in each group was revealed (p>0,05). In the second group, the residual LAA cavity after applying a purse string suture was revealed. During the follow-up period, there were no neurological complications and deaths.Conclusion. According to the study results, it was found that the proposed two-suture technique for LAA occlusion is not less effective than the purse-string suture. The developed technique of two-suture epicardial occlusion of LAA showed actual technical advantages, allowing to optimize this surgery in different categories of patients.

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Reinforcement of the pelvic diaphragm using a purse-string suture in dogs: description of technique

Arquivo Brasileiro de Medicina Veterinária e Zootecnia ◽

10.1590/1678-4162-9025 ◽

2017 ◽

Vol 69 (1) ◽

pp. 89-94

Author(s):

P.C. Moraes ◽

A.C. Facin ◽

N.M. Rosa-Ballaben ◽

N.M. Zanetti ◽

L.G.G.G. Dias

Keyword(s):

Surgical Technique ◽

Perineal Hernia ◽

Surgical Reconstruction ◽

Purse String Suture ◽

Purse String ◽

Anatomical Structures ◽

Physical Support ◽

Pelvic Diaphragm ◽

Suture Placement

ABSTRACT Recurrence of perineal hernias is frequent, and is associated to poor identification of anatomical structures during surgery, inadequate suture placement, and failure of physical support of the pelvic diaphragm after surgical reconstruction. The objective of this work is to describe a novel surgical technique for reinforcement of the pelvic diaphragm after performing the internal obturator transposition technique in dogs with perineal hernia.

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Secondary nipple reconstruction using two surgical techniques

Archives of Plastic Surgery ◽

10.5999/aps.2021.00304 ◽

2021 ◽

Vol 48 (6) ◽

pp. 590-598

Author(s):

Jae-Ho Chung ◽

Da-Som Kim ◽

Hyun-Dong Yeo ◽

Seung-Pil Jung ◽

Seung-Ha Park ◽

...

Keyword(s):

Retrospective Review ◽

Surgical Techniques ◽

Nipple Reconstruction ◽

Purse String Suture ◽

Purse String ◽

Multiple Causes

Background Although the initial projection after primary nipple reconstruction is excellent, nipple projection gradually flattens in most cases due to multiple causes. Although various methods have been reported to rebuild the nipple after nipple flattening, the most effective method of secondary nipple reconstruction remains unknown. The aim of this study was to review our institution’s experiences with secondary nipple reconstruction.Methods We conducted a retrospective review from March 2012 to January 2019. We performed secondary nipple reconstruction if the primary reconstructed nipple height differed by more than 6 mm from the normal nipple height. We chose the method of nipple revision according to the degree of tissue scarring and the remaining nipple projection.Results We performed secondary nipple reconstruction on a total of 27 nipples, using pursestring sutures for 19 nipples and star flaps in eight nipples. The median follow-up period was 8 months (range, 6–19 months) after the final nipple reconstruction. Among the 19 nipples reconstructed using purse-string sutures, 10 (53%) demonstrated acceptable projection of more than 5 mm. Among the eight nipples reconstructed using star flaps, six (75%) showed acceptable projection of more than 5 mm. Most of the patients (73%) were satisfied (scores of 4 or 5) with the nipple reconstruction overall.Conclusions Few studies have presented favorable outcomes of secondary nipple reconstruction. When the star flap and purse-string suture methods were used depending on the remaining nipple height and scarring, appropriate projection could be achieved.

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Surgical left atrial appendage closure: success rate and its relationship with cerebrovascular accident

Current Journal of Neurology ◽

10.18502/cjn.v20i4.8350 ◽

2022 ◽

Author(s):

Mohammad Mahdi Peighambari ◽

Firoozeh Moradkarami ◽

Anita Sadeghpour ◽

Bahador Baharestani ◽

Alireza Alizadeh-Ghavidel ◽

...

Keyword(s):

Success Rate ◽

Significant Relationship ◽

Cerebrovascular Accident ◽

Left Atrial ◽

Left Atrial Appendage ◽

Surgical Techniques ◽

Atrial Appendage ◽

String Method ◽

Purse String ◽

Laa Closure

Background: Several surgical procedures such as excision or exclusion are recommended for the closure of the left atrial appendage (LAA). This study was conducted with the aim to evaluate the success rate of different surgical techniques for LAA closure, their respective complications, and the rate of post-surgical cerebrovascular accident (CVA). Methods: This retrospective study included 150 consecutive patients who underwent LAA closure most commonly after mitral valve surgery within 3 to 6 months after surgery. An expert echocardiographic fellow collected the data on patients’ surgical LAA closure methods and history of CVA, types of prosthetic valves, mortality, and bleeding. Results: The failure rate for complete LAA closure was 36.7% (55 patients) in our study. The greatest success rate of complete LAA closure was seen in purse-string method (75.5%), followed by resection method (71.4%), while the lowest success rate (≈ 33.3%) was observed in ligation method. A significant relationship was observed between clots on the surface of metallic valve and postoperative CVA (P = 0.001; likelihood ratio: 32). significant relationship between partial LAA closure and the incidence of post-surgical CVA (P > 0.050). Conclusion: We observed the highest success rate of complete LAA closure in purse-string method followed by resection method. Interestingly, our results showed that despite the higher rate of residual LAA clot in cases of partial LAA closure, the occurrence of post-surgical CVA was mostly related to the presence of clots on the surface of metallic mitral prostheses rather than the presence of partial LAA closure.

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Surgical technique of using absorbable, knotless, unidirectional barbed suture as a modified purse string suture

Journal of Visualized Surgery ◽

10.21037/jovs-20-148 ◽

2021 ◽

Vol 0 ◽

pp. 0-0

Author(s):

Thirugnanam Agasthian

Keyword(s):

Surgical Technique ◽

Barbed Suture ◽

Purse String Suture ◽

Purse String

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Reduced Incidence of Thromboembolic Events after Surgical Closure of Left Atrial Appendage in Patients with Atrial Fibrillation

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000231 ◽

2016 ◽

Vol 11 (1) ◽

pp. 24-30 ◽

Cited By ~ 3

Author(s):

Manuel Wilbring ◽

Friedrich Jung ◽

Christoph Weber ◽

Klaus Matschke ◽

Michael Knaut

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Thromboembolic Events ◽

Surgical Ablation ◽

Closure Group ◽

Laa Closure

Objective Most of the detected thrombi in patients with atrial fibrillation (AF) can be found in the left atrial appendage (LAA). Interventional LAA closure recently proved to be noninferior to warfarin therapy. Whether these results can be fully translated into surgical LAA closure remains unclear. Corresponding data are still lacking. The present observational study evaluated the impact of surgical LAA closure in patients with AF undergoing cardiac surgery on postoperative thromboembolic events. Methods A prospective registry enrolled 398 patients with permanent AF undergoing cardiac surgery. Concomitant procedures were isolated surgical ablation (group I, n = 71), isolated LAA closure (group II, n = 44), and combined surgical ablation and LAA closure (group III, n = 196). The control group consisted of 87 patients without concomitant surgical ablation or LAA closure. One-year follow-up was completed in all patients. End points were thromboembolic events and death from any cause. Results Clinical baseline characteristics were comparable among the groups. General hospital mortality was 5.5% and likewise differed not significantly. Postoperatively, mean (SD) CHAD2S2-VASc score of 3.5 (1.3) differed not significantly among the groups, indicating comparable thromboembolic risk. Follow-up referred to all hospital survivors (n = 376). Herein, overall incidence of thromboembolic events was 9.8% (n = 37), with an associated mortality of 41.0%. Patients with LAA closure alone or in combination with surgical ablation had a significantly reduced incidence of thromboembolic events (6.6% vs 20.5%, P < 0.01) and consecutively improved survival after 1 year of follow-up (7.0% vs 17.1%, P < 0.01). Conclusions Left atrial appendage closure alone or in combination with surgical ablation was associated with a significantly reduced rate of thromboembolic events and consecutively improved survival after 1 year of follow-up.

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Comparison of Stump Burying using Laparoscopic and Open Methods in Complicated Acute Appendicitis

Bakirkoy Tip Dergisi / Medical Journal of Bakirkoy ◽

10.5222/bmj.2020.59254 ◽

2020 ◽

Author(s):

Sina Ferahman ◽

Turgut Dönmez ◽

Serhan Yılmaz ◽

Sezer Akbulut ◽

Ahmet Sürek ◽

...

Keyword(s):

Acute Appendicitis ◽

Hospital Stay ◽

Surgical Complications ◽

Open Appendectomy ◽

Surgical Techniques ◽

Laparoscopic Technique ◽

Purse String Suture ◽

Purse String ◽

Appendiceal Stump ◽

Complicated Acute Appendicitis

Objective: The choice of laparoscopic technique in the treatment of complicated acute appendicitis (CAA) harbours debatable evidence because of higher rates of surgical complications such as postoperative intraabdominal abscess (POIIA). The aim of this study is to compare postoperative results of appendiceal stump (AS) ligation and its burial into the cecum using laparoscopic or open surgical techniques in patients with CAA. Method: This is a single-center and retrospective analysis of patients with CAA operated between May 2018 and April 2020. AS was intracorporeally knotted with silk and buried in the cecum with a purse-string suture (PSS). The patients were divided into open appendectomy (OA) and laparoscopic appendectomy (LA) groups. Data concerning demographic characteristics, intraoperative variables, hospital stay, surgical complications, morbidities, and postoperative findings were compared. Results: A total of 66 patients including 36 patients (54.54%) underwent LA and 30 patients had OA were enrolled in the study. Partial resection of cecum was performed in one patient in the OA group and two patients in the LA group with the help of a stapler due to cecal floor necrosis. The operative time and duration of hospital stay were significantly shorter in the LA group compared to the OA group. Surgical site infection and POIAA were significantlymore frequent in the OA group (p<0.001). Conclusion: In acute complicated appendicitis, laparoscopic method can be applied as an effective method by closing the appendiceal stump and burying into the cecum with a purse-string suture.

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Impact of oral anticoagulation therapy on postoperative atrial fibrillation outcomes: a systematic review and meta-analysis

Thrombosis Journal ◽

10.1186/s12959-021-00342-2 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Mariana Fragão-Marques ◽

Francisco Teixeira ◽

Jennifer Mancio ◽

Nair Seixas ◽

João Rocha-Neves ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Oral Anticoagulation ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Random Effect ◽

Anticoagulation Therapy ◽

Thromboembolic Events ◽

Oral Anticoagulation Therapy ◽

All Cause Mortality

Abstract Background Post-operative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Recent studies had shown this phenomenon is no longer considered transitory and is associated with higher risk of thromboembolic events or death. The aim of this study was to systematically review and analyze previous studies comparing oral anticoagulation therapy with no anticoagulation, regarding these long-term outcomes. Methods PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Database were systematically searched to identify the studies comparing the risk of stroke, or thromboembolic events or mortality of POAF patients who received anticoagulation compared with those who were not anticoagulated. Incidence of stroke, thromboembolic events and all-cause mortality were evaluated up to 10 years after surgery. Time-to-event outcomes were collected through hazard ratio (HR) along with their variance and the early endpoints using frequencies or odds ratio (OR). Random effect models were used to compute statistical combined measures and 95% confidence intervals (CI). Heterogeneity was evaluated through Q statistic-related measures of variance (Tau2, I2, Chi-squared test). Results Eight observational cohort studies were selected, including 15,335 patients (3492 on Oral Anticoagulants (OAC) vs 11,429 without OAC) that met the inclusion criteria for qualitative synthesis. Patients had a wide gender distribution (38.6–82.3%), each study with a mean age above 65 years (67.5–85). Vitamin K antagonists were commonly prescribed anticoagulants (74.3–100%). OAC was associated with a protective impact on all-cause mortality at a mean of 5.0 years of follow-up (HR is 0.85 [0.72–1.01]; p = 0.07; I2 = 48%). Thromboembolic events did not differ between the two treatment arms (HR 0.68 [0.40–1.15], p = 0.15). Conclusion Current literature suggests a possibly protective impact of OAC therapy for all-cause mortality in patients with new-onset atrial fibrillation after cardiac surgery. However, it does not appear to impact thromboembolism rate.

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