Editorial
Electrical Isolation of the Left Atrial Appendage: Is It Safe?
Nathaniel Thompson, MD; Pierre Jaïs, MD
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ulmonary vein isolation is an accepted cornerstone for
all atrial fibrillation (AF) ablation.1 This is true for both
paroxysmal and persistent AF, although other atrial structures have been demonstrated to be involved in the initiation
and maintenance of AF,2–4 including the left atrial appendage
(LAA).5 Di Biase et al,6 demonstrated that the LAA may be
responsible for AF recurrence in a subset of patients, and isolation of the LAA could achieve freedom of AF in patients
with demonstrated triggered activity. Electric uncoupling
of the LAA is not without its potential risks. However, the
authors reported that thrombus was not observed in any of the
204 patients with electric LAA isolation. No cerebrovascular
events were reported.
and cerebrovascular events, although it did not reach statistical significance. Significantly, the authors report that in 1
patient with stroke, LAA reconnection was confirmed at the
time of LAA closure, implicating that alteration of contractility alone is enough to create a risk for a cerebrovascular event.
However, no details are provided on the mechanical performance of the reconnected appendage and on the timing of its
contraction in the cardiac cycle, if any. One could argue that
any ablation strategy with significant alteration of LAA conduction and contractility is an unnecessary risk.
There are ethical concerns about the extensive ablation strategy used by Rillig et al,7 particularly in patients with paroxysmal AF (40% of patients who underwent LAA isolation). After
pulmonary vein isolation, the majority of patients with LAA
isolation received a mitral isthmus line (94%) and an anterior
line (90%). Linear lesions sets are effective to break the circuits
of macro-reentrant tachycardias, and to a lesser degree transect
the reentrant circuits of persistent AF.8–10 However, there is a
little effective role for linear lesions for paroxysmal AF and as
such poses an unnecessary risk for the patient. In addition, the
combination of a mitral line and anterior line seems to be a poor
choice because the addition of these linear lesions yielded unintentional LAA isolation in 42% of patients.
As it stands, electric isolation of the LAA remains controversial and should only be attempted in selected cases with
more limited ablation lesion sets, rigorous use of oral anticoagulation, and a preference for the use of LAA occlusion
devices. What is unknown is what if any ablation strategy to
isolate the LAA is truly safe. The more limited strategy used
by Di Biase et al6 appears as a more prudent option, although
as we have seen, altered conduction alone is a potential risk of
a thromboembolic event. More work is required to delineate
the risks, benefits, and hemodynamic impact of LAA isolation, and the methods to achieve this. We must thank Rillig
et al7 for reporting what had been a more theoretical risk with
electric LAA isolation, and their work should serve as an
important guide and resource to the reader.
See Article by Rillig et al
In this issue of Circulation: Arrhythmia and
Electrophysiology, Rillig et al7 present their investigations of
electric LAA isolation and the incidence of LAA thrombus and
cerebrovascular events. They report cerebrovascular events in
3 of 50 patients (stroke in 2 patients and transitory ischemic
attack in 1 patient), who underwent LAA electric isolation. In
addition to these 3 symptomatic complications, another 21%
of patients had thrombus detected by transesophageal echocardiogram. Oral anticoagulation was recommended for all
patients and LAA closure in patients who underwent LAA
electric isolation. Of the 3 cerebrovascular events, 1 did not
receive oral anticoagulation, whereas of the 10 patients who
had LAA clot detected, 1 did not receive oral anticoagulation.
In comparison, in the control group of 50 patients who did not
undergo LAA electric isolation, there were no LAA thrombi
detected or cerebrovascular events.
These findings raise serious concerns about the safety
of electric isolation of the LAA, in the context of an extensive ablation procedure, and are in contrast to the results
published by Di Biase et al.6 The authors point out that the
high incidence of LAA thrombus detected on transesophageal echocardiogram could be explained by a more extensive approach than that of Di Biase et al,6 with a wider area
of atrium used to isolate the appendage. There was a trend
toward a larger isolated area in patients with LAA thrombus
Disclosures
None.
References
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the CHU Bordeaux, Université de Bordeaux, IHU LIRYC ANR10-IAHU-04, Bordeaux, France.
Correspondence to Nathaniel Thompson, MD, Hôpital Cardiologique
du Haut-Lévêque, Ave Magellan, 33600 Pessac, France. E-mail n.clark.
[email protected]
(Circ Arrhythm Electrophysiol. 2016;9:e004209.
DOI: 10.1161/CIRCEP.116.004209.)
© 2016 American Heart Association, Inc.
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MS, Chen SA. Initiation of atrial fibrillation by ectopic beats originating
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DOI: 10.1161/CIRCEP.116.004209
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2 Thompson and Jaïs Left Atrial Appendage Isolation
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Key Words: editorials ◼ atrial appendage ◼ atrial fibrillation ◼ stroke
Downloaded from http://circep.ahajournals.org/ by guest on June 17, 2017
Electrical Isolation of the Left Atrial Appendage: Is It Safe?
Nathaniel Thompson and Pierre Jaïs
Downloaded from http://circep.ahajournals.org/ by guest on June 17, 2017
Circ Arrhythm Electrophysiol. 2016;9:
doi: 10.1161/CIRCEP.116.004209
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Correction
In the editorial by Thompson and Jaïs (Thompson N, Jaïs P. Electrical isolation of the left atrial
appendage: is it safe? Circulation: Arrhythmia and Electrophysiology. 2016;9:e004209, doi:
10.1161/CIRCEP.116.004209), which published May 6, 2016, and appeared in the May 2016 issue
of the journal, corrections were needed.
The authors apologize for this error.
On p 1, left column, lines 11–13 of the second paragraph, the sentence that read “Of the 3
cerebrovascular events, 1 did not receive OCA, whereas of the 10 patients who had LAA clot
detected, 1 did not receive OCA” has been corrected to read, “Of the 3 cerebrovascular events, 1
did not receive oral anticoagulation, whereas of the 10 patients who had LAA clot detected, 1 did
not receive oral anticoagulation.”
These corrections have been made to the current version of the article, which is available at
http://circep.ahajournals.org/content/9/5/e004209.full.
(Circ Arrhythm Electrophysiol. 2016;9:e000016. DOI: 10.1161/HAE.0000000000000016.)
© 2016 American Heart Association, Inc.
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org
1
DOI: 10.1161/HAE.0000000000000016