Author + information
- Andreu Porta-Sánchez, MD, MS∗ (, )@aportasanchez,
- Gonzalo Pizarro, MD, PhD,
- Óscar Salvador-Montañés, MD,
- Damián Sánchez-Quintana, MD, PhD and
- José Ángel Cabrera, MD, PhD
- ↵∗Unidad de Arritmias, Servicio de Cardiología, Hospital Universitario Quirónsalud Madrid and Universidad Europea de Madrid (UEM), Centro Nacional de Investigaciones Cardiovasculares (CNIC), Calle Melchor Fernández Almagro 3, Madrid, Spain
The recent work by Turagam et al. (1) found a significant reduction in systolic blood pressure after epicardial left atrial appendage (LAA) exclusion when compared with the endocardial method. Although the procedural risks associated with epicardial LAA exclusion have decreased significantly over the years, the initial reports showed a complication rate of 11.5% (2).
We would like to highlight important LAA anatomic features (Figure 1) that are especially relevant when performing the epicardial LAA exclusion procedure:
1. The risk of perforation of the LAA as a result of its nonuniform wall thickness is well established.
2. The leftward extension of the Bachmann bundle (BB) bifurcates around the neck of the LAA, and this could be damaged during LAA exclusion, thus causing enhanced anisotropic conduction and increased arrhythmic risk.
3. The vascular relationships of the LAA are key. The distance of the LAA to the atrioventricular groove is remarkably variable among individuals. In some cases, the close distance between the LAA ostium and the left circumflex artery makes this artery a vulnerable structure when snaring the LAA. Additionally, around 30% to 40% of patients have the sinus node artery originating from their left circumflex artery and in 8% from the left lateral atrial artery (3). When this happens the sinus node artery has an S-shaped course between the LAA and the left superior pulmonary vein.
4. Around 20% to 25% of individuals have their left phrenic nerve running over the anterior neck of the LAA with its pericardiophrenic vessels (4).
5. The LAA is a densely innervated structure, and the consequences of necrotizing these autonomic nerves can play a role in the blood pressure–lowering effect, but this is still poorly understood.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- Turagam M.K.,
- Vuddanda V.,
- Verberkmoes N.,
- et al.
- Sievert H.,
- Rasekh A.,
- Bartus K.,
- et al.
- Cabrera J.A.,
- Saremi F.,
- Sanchez-Quintana D.