Atrial fibrillation can cause cerebral infarction
Atrial fibrillation (AF) is common in elderly patients and is responsible for approximately a quarter of ischemic strokes, most of which are cardioembolic and originate from the left atrial appendage (LAA). In AF patients, the blood flow often stagnates in the left atrium and especially in the LAA, potentially causing clot formation.
Therefore, AF patients generally take a kind of anticoagulants to prevent intracardiac clot formation. However, despite such oral anticoagulation therapy, cardiogenic strokes occur at the rate of approximately 2-4 event/100 pts-year. Additionally, oral anticoagulation may induce hemorrhagic complication such as cerebral or intestinal bleeding. These are drawbacks of anticoagulation therapy in AF patients.
Merit of left atrial appendage resection
In Tokushima University Hospital, we have introduced so-called “Wolf-Ohtsuka procedure” in 2022, in which LAA is resected with the help of thoracoscope. It was the first case in Shikoku region. Because there is no longer space to form clots after LAA resection, almost all patients do not need to take anticoagulants any more even if AF remains. In other words, the risk of not only cerebral infarction but also hemorrhagic complication is eliminated by resecting LAA. Dr. Ohtsuka, who is the pioneer of the procedure and has experienced more than 2500 cases, reported that the incidence of cerebral infarction after Wolf-Ohtsuka procedure was only 0.25 event/100 pts-year.
There are several reports demonstrating other merits of LAA resection in AF patients. Some reported that epicardial LAA exclusion could significantly reduce blood pressure in patients with AF and hypertension and others reported that there were favorable substantial differences in hemodynamics and neurohormonal effects of LAA exclusion with epicardial and endocardial devices. It can be said that there is no demerit but only merit in resecting LAA, because in AF patients LAA does not have normal hemodynamic function but include only high risk of clot formation inside.
Less invasive surgery using a thoracoscope
We perform “Wolf-Ohtsuka procedure” utilizing a thoracoscope (Fig. left panel). In the case of LAA resection alone, we make 4 small skin incision (5 to 12 mm) on the left lateral chest wall (Fig. right panel) and resect LAA through these small holes using a surgical stapler while viewing the endoscopic monitor. The operation time is generally around 50 minutes and the patient can go home 3 to 5 days after surgery. In terms of rhythm control, we often add PVI (pulmonary vein isolation: surgical ablation technique for rhythm control) with LAA resection for the patients with short-term AF history or paroxysmal AF because such patients are more likely to regain sinus rhythm. In this procedure, we need to make additional 4 small skin incision on the right-side chest wall as well and the operation takes around 2 hours.
The good indication for “Wolf-Ohtsuka procedure” is a patient with chronic or paroxysmal nonvalvular AF, who suffers from cerebral infarction despite anticoagulation, who do not want to take or cannot continue anticoagulation therapy due to hemorrhagic complication or other social reason, or who is diagnosed as contra-indicated for percutaneous catheter radiofrequency ablation1. There is no age limit for this procedure. Please feel free to contact us or other specialists when you have any trouble in arrhythmia or anticoagulation therapy.
- catheter radiofrequency ablation: catheter radiofrequency ablation is a percutaneous endovascular procedure that uses radiofrequency energy to modify cardiac arrhythmia. ↩︎