James L. Cox, MD The Journal of Thoracic and Cardiovascular Surgery

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Date of download: 6/25/2016 Copyright © The American College of Cardiology. All rights reserved. From: Mechanism, localization and cure of atrial arrhythmias.

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Mechanical closure of the left atrial appendage: Is it time to be more aggressive? James L. Cox, MD The Journal of Thoracic and Cardiovascular Surgery Volume 146, Issue 5, Pages 1018-1027.e2 (November 2013) DOI: 10.1016/j.jtcvs.2013.07.011 Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Anatomy of the right atrium showing the relatively large size of the orifice of the right atrial appendage in relation to its depth. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1018-1027.e2DOI: (10.1016/j.jtcvs.2013.07.011) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Anatomy of the left atrium showing the relatively small size of the orifice of the left atrial appendage (LAA) in relation to its depth. LSPV, Left superior pulmonary vein; SVC, superior vena cava; LPA, left pulmonary artery; RSPV, right superior pulmonary vein; PT, pulmonary trunk; RPA, right pulmonary artery; LA, left atrium; MV, mitral valve; LV, left ventricle; IVC, inferior vena cava. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1018-1027.e2DOI: (10.1016/j.jtcvs.2013.07.011) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Postoperative electrograms of the right atrium, left atrium (L.A.), right ventricle, and lead II electrocardiogram are recorded during simultaneous monitoring of the cardiac output (aortic flow), systemic arterial blood pressure (B.P.), left ventricular end-diastolic pressure (LVEDP), and pulmonary artery (P.A.) pressure. In the control tracings, the right and left atria are both being paced, but the pacing stimulus to the left atrium is delayed 30 ms to simulate the exact activation pattern that existed preoperatively during normal sinus rhythm. The pacing stimulus to the left atrium is then abruptly discontinued (Silent L.A.). No alterations in normal atrioventricular conduction from the right atrium occur, yet there is no change in left ventricular preload, afterload, or cardiac output. The left atrium is then paced at a rate of 300 pulses/min (L.A. SVT), with no alteration in normal atrioventricular conduction from the right atrium or in the preload, afterload, or cardiac output. SVT, Supraventricular tachycardia; ECG, electrocardiogram. (Reproduced with permission from Williams et al.37) The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1018-1027.e2DOI: (10.1016/j.jtcvs.2013.07.011) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Disappearance of the left atrial appendage (LAA) after application of the external surgical AtriClip. (Modified from Ailawadi et al.12) The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1018-1027.e2DOI: (10.1016/j.jtcvs.2013.07.011) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Disappearance of the left atrial appendage (LAA) after application of the external percutaneous Lariat. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1018-1027.e2DOI: (10.1016/j.jtcvs.2013.07.011) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions