Medium-to-Long-Term Success Rate of Left Atrial Appendage Closure Using Endocardial Sutures and Postoperative Anticoagulant Strategies

Medium-to-Long-Term Success Rate of Left Atrial Appendage Closure Using Endocardial Sutures and Postoperative Anticoagulant Strategies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Medium-to-Long-Term Success Rate of Left Atrial Appendage Closure Using Endocardial Sutures and Postoperative Anticoagulant Strategies Wenzhong Heng, Hongying Song, Rong Zhang, Shibo Zhou, Maoxun Huang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5448337/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Surgical endocardial closure of the left atrial appendage (LAA) is reported to reduce the risk of stroke in patients with atrial fibrillation (AF). This retrospective study assessed the efficacy and safety of endocardial suture obliteration with medium-to-long-term follow-up. Methods A total of 50 patients with valvular diseases and AF, treated from 2013 to 2018, were included in the analysis. All underwent heart valve surgery, the Cox-Maze IV procedure, and LAA closure using the endocardial suture obliteration technique. Intraoperative transesophageal echocardiography (TEE) was performed to assess the LAA closure outcomes. Closure failure was defined as a remnant LAA (> 1 cm) or persistent flow between the left atrium (LA) and LAA. Patients were followed up for an average of 7.16 ± 1.73 years, with transthoracic echocardiography (TTE) and TEE used to assess the results. Results Intraoperative TEE revealed no remnants of the LAA or persistent flow in any patient post-closure. None of those monitored postoperatively with TEE exhibited a remnant LAA > 1 cm; however, 5 (10%) patients had persistent flow between the LA and LAA. Of these five patients with closure failure, four (75%) presented with thrombus in the LAA stump, and one experienced a stroke event. Conclusion Our center has widely adopted the intraoperative closure of the LAA due to its simplicity, minimal bleeding risk, cost-effectiveness, and high success rate. For patients with confirmed LAA closure based on TEE evaluation, continued use of anticoagulant drugs may not be necessary. atrial fibrillation left atrial appendage closure cardiac procedures valvular heart disease Figures Figure 1 Figure 2 Figure 3 Background Atrial fibrillation (AF) is the most common arrhythmia and a significant source of thromboembolic events, increasing stroke risk by 2.4-fold compared to patients without AF( 1 ). The left atrial appendage (LAA) is a primary site for thrombus formation in patients with AF, with studies showing that the LAA is the source of thrombus in 90% of the nonrheumatic AF cases among patients with stroke( 2 ). Therefore, LAA occlusion or closure is crucial in preventing thromboembolic events. Surgical left atrial appendage occlusion (S-LAAO) has effectively reduced stroke risk( 3 – 5 ).The latest American College of Cardiology (ACC) guidelines recommend treating LAA during combined valve surgery( 6 ). Various techniques for S-LAAO have been proposed, including surgical excision, stapled excision, and certified surgical closure devices (such as AtriClip [AtriCure, Inc., Mason, US])( 7 , 8 ). Different results have been reported regarding these techniques. The traditional method of endocardial suture for S-LAAO, popularized in 2000, showed a 64% success rate according to transesophageal echocardiography (TEE)( 9 ). However, subsequent reports have shown mixed success rates for the endocardial suture technique, ranging from 23–89.7%( 10 , 11 ). Due to their overall low success rate and the development of multiple S-LAAO methods, the application of endocardial suture techniques is currently limited. This study aimed to investigate the effects of the endocardial closure technique on the LAA and summarize the experience of LAA closure failure. It further discussed the risk of future thrombosis and the appropriate maintenance of anticoagulant drugs to ensure a lower incidence of stroke. METHODS 2.1 Patient Selection The study adhered to the principles of the Declaration of Helsinki (revised in 2013) and was approved by the ethics board of the Second Hospital of Jilin University (No. 2024 [076]). From September 2013 to September 2018, 306 patients were preoperatively diagnosed with valvular heart diseases combined with AF using transthoracic echocardiography (TTE) and electrocardiogram (ECG). All patients underwent open-heart valvular surgery combined with AF radiofrequency ablation (Cox-Maze IV procedure) and LAA closure using the endocardial suture technique. Strict inclusion and exclusion criteria were established for the study. Inclusion criteria: ( 1 ) AF diagnosis confirmed preoperatively by ECG; ( 2 ) valvular heart disease confirmed by color Doppler ultrasound and surgical indications (including valve stenosis, insufficiency affecting the heart's ability to pump blood, and ineffective drug treatment). Exclusion criteria: ( 1 ) patients with abnormal coagulation function, systemic infection, or malignant tumor; ( 2 ) severe liver or kidney dysfunction, or mental disorders; ( 3 ) refusal to undergo TEE; ( 4 ) contraindications to TEE (such as esophageal stenosis or diverticulum, or severe cervical dislocation). 2.2 Surgical Procedures and Operative Data All patients underwent valvular surgery under general anesthesia and cardiopulmonary bypass (CPB). Patients were placed in a supine position, and a median thoracotomy was performed. CPB was established via cannulation of the aorta, and the superior and inferior vena cava. Intraoperative TEE was used to observe the functional status of each valve. The ascending aorta was clamped after reaching the target temperature, and circulation arrest was performed. A bipolar radiofrequency clamp was utilized for linear ablation lines of both the left atrium (LA) and right atrium (RA), following the Cox-Maze IV ablation route, to obstruct the reentry ring and effectively treat AF( 12 ). After the ablation procedure, an incision was made in the LA to expose its interior. A 4 − 0 polypropylene suture was used for continuous suturing along the junction of LA and LAA, from the upper to the lower margin. The single-layer simple running suture technique is employed, ensuring that the typical distance between the needle and neighboring needle does not exceed 2 mm. Strict control over strength, angle, and uniformity is imperative, while completing the procedure expeditiously(Fig. 2 ). Based on the intraoperative assessment of valve condition, repair or replacement of either aortic or mitral valve was performed post-ablation. In patients with severe coronary artery disease confirmed by preoperative coronary angiography, coronary artery bypass grafting (CABG) was conducted. After completing these operations, patients were gradually weaned off CPB. The remainder of the surgical procedure was performed as customary, including hemostasis, placement of temporary pacemaker leads for backup support, and closure of incisions. 2.3 TEE Evaluation of LAA Closure Following intraoperative cardioversion, all patients underwent multiplane TEE to assess LAA closure from various angles (0 to 120°), conducted by an experienced echocardiologist. The evaluation included: ( 1 ) the assessment of continuous blood flow between LAA and LA using color Doppler; ( 2 ) the measurement of the maximum length of LAA post-closure. Criteria for closure failure were defined as a maximum stump length > 1 cm or persistent flow between LAA and LA, indicating early closure failure. 2.4 Postoperative Anticoagulation Management All patients received warfarin for anticoagulation management. Those with mechanical valve replacement (VR) were prescribed lifelong anticoagulation. Target international normalized ratio (INR) levels were maintained at 1.8–2.5 for patients with mechanical VR. Patients who underwent CABG received long-term aspirin (100 mg/day) in addition to their regimen. Patients with biologic or valvuloplasty were anticoagulated for 6 months, with an INR target of 1.8–2.5. Patients who underwent CABG received a duration of 6 months aspirin (100 mg/day) in addition to their regimen. Following this, a combination of aspirin and clopidogrel (75 mg/day) was administered for 6 months, with aspirin being continued as a long-term maintenance therapy after the completion of 1 year. 2.5 Follow-up Enrolled participants underwent follow-up examinations using both TEE and TTE. The same criteria were applied to assess successful or unsuccessful LAA closure. Moreover, TEE recorded the remaining LAA length, and surveillance for thrombus in LA or residual LAA was conducted. LAA size was measured using TTE. Following postoperative assessments, all patients underwent regular INR testing as per protocol. Warfarin dosage adjustments were made under the guidance of anticoagulation specialists to maintain INR within the therapeutic range. The postoperative anticoagulation status of all patients was analyzed, including the duration of warfarin administration, the target INR range, and the occurrence of cerebral embolism.The time in therapeutic range (TTR) during oral warfarin administration was determined using the method of fraction of INRs in range in all patients. Embolic events were defined as clinical signs confirmed by computed tomography or angiography (neurological events). 2.6 Statistical Analysis Statistical analysis was conducted using IBM SPSS (Version 27.0) (IBM Corporation, Armonk, NY, USA). Descriptive statistics are presented as mean ± standard deviation (SD) or n (%), and categorical data as n (%). Paired sample t-tests were utilized to compare left atrial size pre- and postoperatively. A one-sided test with P < 0.05 was considered statistically significant. RESULT 3.1 Operative Data A total of 50 patients (16 men and 34 women, aged 54.56 ± 7.71 years) participated in the study (Fig. 1 ). The preoperative data of these patients are summarized in Table 1 . The average size of the left atrium was 52.08 ± 10.60mm, and the ejection fraction was 57.74 ± 7.28%. Long-lasting AF accounted for the most significant proportion at 52%. Table 1 Preoperative Patient Characteristics Variable n = 50 Age (years) 54.56 ± 7.71 Female, n(%) 34 (68%) Body surface area (m 2 ) 1.63 ± 0.18 BMI (kg/m 2 ) 24.06 ± 3.66 LVEF (%) 57.74 ± 7.28 Creatinine (mg/dL) 76.32 ± 21.04 Diameter of the LA (mm) 52.08 ± 10.60 serum creatinine (mg/dL) 76.32 ± 21.04 Diabetes, n(%) 5 (10%) Hypertension, n(%) 8 (16%) Cerebrovascular disease, n(%) 5 (10%) Previous incidence of stroke, n(%) 1 (2%) Chronic lung disease, n(%) 7 (14%) NYHA class, n(%) Class 3 34 (68%) Class 4 16 (32%) Coronary heart disease, n(%) 11 (22%) Previous catheter ablation, n(%) 0 Atrial fibrillation type, n(%) Paroxysmal 6 (12%) Long-term persistence 18 (36%) Persistent 26 (52%) BMI, Body mass index; LVEF, left ventricular ejection fraction; LA: left atrium; NYHA, New York Heart Association. The mean CPB duration was 136.94 ± 38.43 minutes (range 70.00–248.00 minutes), and aortic occlusion lasted on average 82.28 ± 26.97 minutes (range 38.00–144.00 minutes). Valvular surgeries included mitral valve procedures in 48 cases, aortic valve surgeries in 14, and tricuspid valve surgeries in 37. Mechanical valve replacements were performed in 28 cases, while biological valve replacements or valvuloplasty were carried out in 22. Other cardiac operations included CABG in five instances and closure of patent foramen ovale with patching in two (Table 2 ). Intraoperative TEE confirmed no residual flow between LAA and LA in all patients, and no remnants were observed in the closed LAA (Table 3 ). Table 2 Intraoperative Patient Data Variable Result Mitral valve treatment, n(%) Bio Mitral 16 (32) Mechanical Mitral 28 (56) Plasty Mitral 6 ( 12 ) Patient’s classification, n(%) MVP 5 ( 10 ) MVP, TVP 1 ( 2 ) MVR 6 ( 12 ) MVR, AVR 4 ( 8 ) MVR, TVP 20 (48) MVR, AVR, TVP 9(20) Concomitant CABG* 4( 8 ) Concomitant CABG** 1( 2 ) Perfusion time (min) 136.94 ± 38.43 Cross-clamp time (min) 82.28 ± 26.97 Prior Thrombotic location, n(%) LAA 5 ( 10 ) LA 4 ( 8 ) Both 4 ( 8 ) MVP, mitral valve plasty; TVP, tricuspid valve plasty; MVR, mitral valve replacement; AVR, aortic valve replacement; LAA, left atrial appendage; LA, left atrium; CABG, coronary artery bypass grafting; * MVR, TVP, ** MVR, AVR, TVP. Table 3 Left Atrial Appendage Closure Details Intraoperative TEE Postoperative TEE Mean follow-up, (years) - 7.16 ± 1.73 Residual stump ≤ 1 cm, n(%) 0 9 ( 18 ) Residual stump > 1 cm, n(%) 0 0 residual shunts, n(%) 5 mm 0 0 TEE, transesophageal echocardiography; LA, left atrium. 3.2 Early clinical outcomes There were no intraoperative or 30-day mortalities. Postoperative complications included atrioventricular block (n = 2 [4%]), peri-prosthetic leak (n = 2 [4%]), and secondary thoracotomy (n = 1 [2%]). There were no incidences of renal insufficiency, cardiac tamponade, or stroke. 3.3 Medium-to-long-term TEE and TTE evaluation Patients were followed up for an average of 7.16 ± 1.73 years, with TTE and TEE used to assess the results. During the medium-to-long-term follow-up,TEE identified one case of biological damage to the mitral valve. Postoperatively, nine (18%) patients exhibited LAA stumps, all measuring < 1 cm; continuous flow between LAA and LA was observed in five (10%), with residual shunt areas ranging between 1–2 mm. Four of the five patients with LAA closure failure underwent intraoperative mechanical valve replacement, three developed LAA thrombosis, and one who had biological valve replacement experienced LAA thrombosis (Table 3 ) (Fig. 3 ). 3.4 Follow-up Data At the follow-up point, all 28 patients who underwent mechanical VR had successfully completed continuous anticoagulant therapy, with a mean time in TTR of their INR reaching 68.5%. The mean TTR of INR for the 22 patients who received Biologic VR / valvuloplasty and completed 6 months of warfarin-based anticoagulation therapy after surgery was found to be 70.8%. Notably, no bleeding complications were observed during warfarin administration among all patients. No stroke events were reported among patients with successful LAA closure. Among the five patients with closure failure, none of the four who underwent mechanical valve replacement experienced stroke events, whereas the patients who received biological valve replacement suffered a stroke 18 months postoperatively (Table 4 ). Table 4 Postoperative Follow-up Findings S-LAAO Recurrent AF Stroke event Mechanical VR (n = 28) Success (n = 24) 4 (16.7%) 0 Failure (n = 4) 1 (25%) 0 Biologic VR /Valvuloplasty (n = 22) Success (n = 21) 7 (33.3%) 0 Failure (n = 1) 0 1 (100%) S-LAAO, Surgical left atrial appendage occlusion; AF, Atrial fibrillation; VR, valve replacement Discussion In patients with AF, intraoperative S-LAAO is pivotal in eliminating a thrombus-prone site. Extensive indirect evidence suggests that successful intraoperative S-LAAO effectively reduces the incidence of stroke events. Conversely, failure to close this structure may elevate the risk of strokes. Therefore, optimizing strategies to enhance the success rate of closure procedures becomes paramount. Intraoperative and postoperative TEE revealed distinct reasons for the failure of various LAA closure techniques. Surgical excision, stapled excision, and AtriClip devices were more prone to failure due to a stump size > 1 cm( 13 – 15 ). Despite a stump size of < 1 cm( 16 ), there remains an increased risk of postoperative thrombus formation, leading to stroke events. The advantage of the endocardial suture technique lies in its minimal residual stump presence; however, suboptimal overall success rates have been reported, with persistent residual shunting between LAA and LA being a common cause of failure. Remarkably, our average follow-up duration of 7.16 years demonstrated an exceptional success rate of 90%, significantly surpassing previous data. From our perspective, key factors contributing to enhanced success rates encompass shortening and ensuring consistency in continuous stitching. A single suture can be replaced with a double suture to reinforce isolation. For LAA openings with irregular shapes, suturing should ensure smoothness on the left atrial side so that uniform force is exerted at each suture line position during atrial contraction. Compared to other techniques for closing the LAA, the endocardial suture technique offers distinct advantages such as procedural simplicity, minimal bleeding, and cost-effectiveness. Provided its success rate can be guaranteed, it represents a superior choice. Unlike Katz et al.’s findings( 9 ), persistent blood flow signals were not observed between LA and LAA through TEE following restoration of heart rhythm. Such continuous flow is hypothesized to manifest during the early postoperative period rather than intraoperatively. Among the five patients who experienced closure failure, residual shunt port lengths ranging from 0.1 to 0.3 mm were observed, indicating leakage between adjacent sutures. For patients with AF, long-term oral anticoagulation and LAA closure are considered distinct strategies to reduce stroke risk. Currently, there is insufficient robust evidence supporting the replacement of long-term anticoagulation with successful LAA closure( 5 ); therefore, the necessity for ongoing oral warfarin in patients with recurrent AF but successful LAA closure remains controversial. In this follow-up study, varying anticoagulation methods were employed based on the type of valve treated intraoperatively. Among patients not receiving long-term anticoagulation (n = 21), 33.3% experienced recurrent AF; however, no strokes occurred during the follow-up. These findings suggest that continued oral anticoagulant therapy may be an unnecessary choice for individuals who have undergone successful S-LAAO, regardless of recurrent AF occurrence. Theoretically, residual shunts between the LA and LAA may lead to blood stasis in the latter. Our central findings revealed that thrombus formation in the LAA occurred in 75% of the patients with closure failure, increasing the risk of thrombotic events upon detachment. Patients who experienced LAA closure failure without long-term anticoagulation suffered stroke events at 18 months postoperatively. While limited studies have explored the correlation between residual shunt diameter and stroke events, percutaneous LAA closure procedures offer a substantial dataset for analysis. One study demonstrated that patients with residual shunts < 5 mm after LAA closure faced increased stroke risk( 17 ). All observed residual shunts in our cohort were small (1–3 mm), suggesting a higher likelihood of stroke events. Therefore, caution should be exercised before discontinuing warfarin anticoagulation in such cases. Therefore, prior to discontinuing warfarin, TEE should be employed to elucidate the status of LAA closure. In the event of unsuccessful closure, consider continuing warfarin anticoagulant therapy. Limitations Our study has several limitations. First, over half of the patients declined to undergo follow-up TEE and were consequently excluded from the screening process. Hence, it is imperative to explore strategies for enhancing patient compliance with follow-up appointments or consider conducting cardiac computed tomography angiography (CTA) for those who refuse TEE examination. This approach would significantly augment the sample size and bolster data credibility. Second,the small size of our follow-up sample may limit its representativeness for the broader population. Moreover,our study exclusively focuses on patients with valvular disease; hence, caution is needed when extrapolating our findings to patients with other heart diseases who do not undergo postoperative anticoagulation. Conclusion Intraoperative LAA closure is widely adopted in our center due to its simplicity, minimal bleeding risk, cost-effectiveness, and high success rate. Before discontinuing anticoagulation therapy, the TEE assessment should verify complete closure. For patients with confirmed LAA closure based on TEE, ongoing anticoagulant therapy may not be necessary; however, those who fail to achieve LAA closure should continue anticoagulation. Declarations Retrospective ethical statement: The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the ethics board of the Second Hospital of Jilin University (No. 2024 [076]). Consent to participate statement: The study was conducted with the informed consent of the participants, who willingly signed the informed consent form. Funding Declaration ： This research was funded by the Health Commission of Jilin Province (grant No. 2022LC113) . Competing interests: The authors declares that they have no competing interests. Acknowledgements : This research was funded by the Health Commission of Jilin Province (grant No. 2022LC113) .We thank Bullet Edits Limited for the linguistic editing and proofreading of the manuscript. Footnote Reporting Checklist: The authors have completed the STROBE reporting checklist. References Odutayo A, Wong CX, Hsiao AJ et al. Atrial fibrillation and risks of cardiovascular disease, renal disease, and death systematic review and meta-analysis. Bmj 2016 354 i4482. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755–9. Park-Hansen J, Holme SJV, Irmukhamedov A, et al. Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: the LAACS randomized study. J Cardiothorac Surg. 2018;13:53. Aryana A, Singh SK, Singh SM, et al. Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization. Heart Rhythm. 2015;12:1431–7. Whitlock RP, Belley-Cote EP, Paparella D, et al. Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. N Engl J Med. 2021;384:2081–91. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149:e1–156. Kabra R, Gopinathannair R, Lakkireddy D. Left Atrial Appendage Occlusion During Cardiac Surgery: A 75-Year-Old Journey. J Am Heart Assoc. 2023;12:e030127. Squiers JJ, Edgerton JR. Surgical Closure of the Left Atrial Appendage: The Past, The Present, The Future. J Atr Fibrillation. 2018;10:1642. Katz ES, Tsiamtsiouris T, Applebaum RM, et al. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol. 2000;36:468–71. García-Fernández MA, Pérez-David E, Quiles J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol. 2003;42:1253–8. Kanderian AS, Gillinov AM, Pettersson GB, et al. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol. 2008;52:924–9. Damiano RJ Jr., Schwartz FH, Bailey MS, et al. The Cox maze IV procedure: predictors of late recurrence. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5448337","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":380761971,"identity":"c1b27ab0-4298-43eb-8907-82c3d767e853","order_by":0,"name":"Wenzhong Heng","email":"","orcid":"","institution":"the Second Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Wenzhong","middleName":"","lastName":"Heng","suffix":""},{"id":380761972,"identity":"ab6acdab-f456-49fa-b588-62f229de1848","order_by":1,"name":"Hongying Song","email":"","orcid":"","institution":"the Second Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Hongying","middleName":"","lastName":"Song","suffix":""},{"id":380761974,"identity":"2a361c7c-417e-4058-86ae-f395cbc77162","order_by":2,"name":"Rong Zhang","email":"","orcid":"","institution":"the Second Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Rong","middleName":"","lastName":"Zhang","suffix":""},{"id":380761976,"identity":"48b77179-62ba-4d23-98be-b07beb5e80b9","order_by":3,"name":"Shibo Zhou","email":"","orcid":"","institution":"the Second Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Shibo","middleName":"","lastName":"Zhou","suffix":""},{"id":380761977,"identity":"c2e555a8-66d2-4957-8c5a-fdbb4f907ba2","order_by":4,"name":"Maoxun Huang","email":"","orcid":"","institution":"the Second Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Maoxun","middleName":"","lastName":"Huang","suffix":""},{"id":380761979,"identity":"f399bd70-8401-4398-a0eb-911b4dfdd978","order_by":5,"name":"Yong Wang","email":"","orcid":"","institution":"the Second Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Wang","suffix":""},{"id":380761981,"identity":"e5467e68-f4a3-4a60-b721-fed263ee9481","order_by":6,"name":"Huiying Wu","email":"","orcid":"","institution":"the Second Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Huiying","middleName":"","lastName":"Wu","suffix":""},{"id":380761982,"identity":"6118b48d-c403-415d-aeeb-598963d245e0","order_by":7,"name":"Tiance Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIie3QsQrCMBCA4ZNIXG7oeKXQNxBOCgGX+iqGDq5O0s0WIT6Db+Gka0uGLgVXR0tfwAcQ1FmQxs0h33z/cQmA5/0htqLuH/yMF01ZdnenpJEZYy4SaO0uIafkgirAVujiujIBuh2GCkIjR+WhM0CQxtNiIFFWbm4zg0JE2tzWkCWqGkzEmbUhKSO9Z4JKn4YTUFQbRgxrQ+iSLOxYhUW7JKKRYzK3Mksgr5hRvz+ZHd7CF1v3wNX2OGm67p6n8WDyueG3cc/zPO+LF5zARD0hjwRVAAAAAElFTkSuQmCC","orcid":"","institution":"the Second Hospital of Jilin University","correspondingAuthor":true,"prefix":"","firstName":"Tiance","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-11-13 15:53:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5448337/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5448337/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71925608,"identity":"831fb6b1-470e-4fca-a977-be90bcb965ff","added_by":"auto","created_at":"2024-12-19 18:39:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":492726,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram outlining the study\u003c/p\u003e\n\u003cp\u003eTEE, transesophageal echocardiography; S-LAAO, Surgical left atrial appendage occlusion.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5448337/v1/e09d409f61bacc6deed50a14.png"},{"id":71925938,"identity":"086b0c29-47c6-405d-b9a3-5b8da1e3f182","added_by":"auto","created_at":"2024-12-19 18:47:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2181712,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of S-LAAO in our study.\u003c/p\u003e\n\u003cp\u003eThe arrow indicates the starting position of S-LAAO; the dashed line indicates the closed position of LAA.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5448337/v1/a0a04b089c6981ec451cf041.png"},{"id":71925610,"identity":"b90db7bc-973d-40c7-9c8b-2b4ea627ef9b","added_by":"auto","created_at":"2024-12-19 18:39:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4911173,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative and postoperative evaluation of LAA closure\u003c/p\u003e\n\u003cp\u003e(A) Successfully closed LAA (without stump and participating in shunt); (B) Successfully closed LA (only stump \u0026lt;1 cm); (C) Residual shunt in LA and LAA (thrombosis observed in the residual LAA); (D) Residual shunt in LA and LAA (the longest diameter of the outlet was measured).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5448337/v1/b4f0e1b319bed332ed8cba80.png"},{"id":98944612,"identity":"8da30ca7-98d8-4ff5-a826-7a07437c2cc0","added_by":"auto","created_at":"2025-12-24 11:55:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10559002,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5448337/v1/fd446b8e-8412-48da-a6ee-49bb8ee344e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Medium-to-Long-Term Success Rate of Left Atrial Appendage Closure Using Endocardial Sutures and Postoperative Anticoagulant Strategies","fulltext":[{"header":"Background","content":"\u003cp\u003eAtrial fibrillation (AF) is the most common arrhythmia and a significant source of thromboembolic events, increasing stroke risk by 2.4-fold compared to patients without AF(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The left atrial appendage (LAA) is a primary site for thrombus formation in patients with AF, with studies showing that the LAA is the source of thrombus in 90% of the nonrheumatic AF cases among patients with stroke(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Therefore, LAA occlusion or closure is crucial in preventing thromboembolic events.\u003c/p\u003e \u003cp\u003eSurgical left atrial appendage occlusion (S-LAAO) has effectively reduced stroke risk(\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).The latest American College of Cardiology (ACC) guidelines recommend treating LAA during combined valve surgery(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Various techniques for S-LAAO have been proposed, including surgical excision, stapled excision, and certified surgical closure devices (such as AtriClip [AtriCure, Inc., Mason, US])(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Different results have been reported regarding these techniques. The traditional method of endocardial suture for S-LAAO, popularized in 2000, showed a 64% success rate according to transesophageal echocardiography (TEE)(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, subsequent reports have shown mixed success rates for the endocardial suture technique, ranging from 23\u0026ndash;89.7%(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Due to their overall low success rate and the development of multiple S-LAAO methods, the application of endocardial suture techniques is currently limited.\u003c/p\u003e \u003cp\u003eThis study aimed to investigate the effects of the endocardial closure technique on the LAA and summarize the experience of LAA closure failure. It further discussed the risk of future thrombosis and the appropriate maintenance of anticoagulant drugs to ensure a lower incidence of stroke.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patient Selection\u003c/h2\u003e \u003cp\u003e The study adhered to the principles of the Declaration of Helsinki (revised in 2013) and was approved by the ethics board of the Second Hospital of Jilin University (No. 2024 [076]). From September 2013 to September 2018, 306 patients were preoperatively diagnosed with valvular heart diseases combined with AF using transthoracic echocardiography (TTE) and electrocardiogram (ECG). All patients underwent open-heart valvular surgery combined with AF radiofrequency ablation (Cox-Maze IV procedure) and LAA closure using the endocardial suture technique.\u003c/p\u003e \u003cp\u003eStrict inclusion and exclusion criteria were established for the study. Inclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) AF diagnosis confirmed preoperatively by ECG; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) valvular heart disease confirmed by color Doppler ultrasound and surgical indications (including valve stenosis, insufficiency affecting the heart's ability to pump blood, and ineffective drug treatment). Exclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) patients with abnormal coagulation function, systemic infection, or malignant tumor; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) severe liver or kidney dysfunction, or mental disorders; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) refusal to undergo TEE; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) contraindications to TEE (such as esophageal stenosis or diverticulum, or severe cervical dislocation).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2.2 Surgical Procedures and Operative Data\u003c/h3\u003e\n\u003cp\u003eAll patients underwent valvular surgery under general anesthesia and cardiopulmonary bypass (CPB). Patients were placed in a supine position, and a median thoracotomy was performed. CPB was established via cannulation of the aorta, and the superior and inferior vena cava. Intraoperative TEE was used to observe the functional status of each valve. The ascending aorta was clamped after reaching the target temperature, and circulation arrest was performed.\u003c/p\u003e \u003cp\u003eA bipolar radiofrequency clamp was utilized for linear ablation lines of both the left atrium (LA) and right atrium (RA), following the Cox-Maze IV ablation route, to obstruct the reentry ring and effectively treat AF(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). After the ablation procedure, an incision was made in the LA to expose its interior. A 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene suture was used for continuous suturing along the junction of LA and LAA, from the upper to the lower margin. The single-layer simple running suture technique is employed, ensuring that the typical distance between the needle and neighboring needle does not exceed 2 mm. Strict control over strength, angle, and uniformity is imperative, while completing the procedure expeditiously(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBased on the intraoperative assessment of valve condition, repair or replacement of either aortic or mitral valve was performed post-ablation. In patients with severe coronary artery disease confirmed by preoperative coronary angiography, coronary artery bypass grafting (CABG) was conducted. After completing these operations, patients were gradually weaned off CPB. The remainder of the surgical procedure was performed as customary, including hemostasis, placement of temporary pacemaker leads for backup support, and closure of incisions.\u003c/p\u003e\n\u003ch3\u003e2.3 TEE Evaluation of LAA Closure\u003c/h3\u003e\n\u003cp\u003eFollowing intraoperative cardioversion, all patients underwent multiplane TEE to assess LAA closure from various angles (0 to 120\u0026deg;), conducted by an experienced echocardiologist. The evaluation included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the assessment of continuous blood flow between LAA and LA using color Doppler; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the measurement of the maximum length of LAA post-closure. Criteria for closure failure were defined as a maximum stump length\u0026thinsp;\u0026gt;\u0026thinsp;1 cm or persistent flow between LAA and LA, indicating early closure failure.\u003c/p\u003e\n\u003ch3\u003e2.4 Postoperative Anticoagulation Management\u003c/h3\u003e\n\u003cp\u003eAll patients received warfarin for anticoagulation management. Those with mechanical valve replacement (VR) were prescribed lifelong anticoagulation. Target international normalized ratio (INR) levels were maintained at 1.8\u0026ndash;2.5 for patients with mechanical VR. Patients who underwent CABG received long-term aspirin (100 mg/day) in addition to their regimen.\u003c/p\u003e \u003cp\u003ePatients with biologic or valvuloplasty were anticoagulated for 6 months, with an INR target of 1.8\u0026ndash;2.5. Patients who underwent CABG received a duration of 6 months aspirin (100 mg/day) in addition to their regimen. Following this, a combination of aspirin and clopidogrel (75 mg/day) was administered for 6 months, with aspirin being continued as a long-term maintenance therapy after the completion of 1 year.\u003c/p\u003e\n\u003ch3\u003e2.5 Follow-up\u003c/h3\u003e\n\u003cp\u003eEnrolled participants underwent follow-up examinations using both TEE and TTE. The same criteria were applied to assess successful or unsuccessful LAA closure. Moreover, TEE recorded the remaining LAA length, and surveillance for thrombus in LA or residual LAA was conducted. LAA size was measured using TTE.\u003c/p\u003e \u003cp\u003eFollowing postoperative assessments, all patients underwent regular INR testing as per protocol. Warfarin dosage adjustments were made under the guidance of anticoagulation specialists to maintain INR within the therapeutic range. The postoperative anticoagulation status of all patients was analyzed, including the duration of warfarin administration, the target INR range, and the occurrence of cerebral embolism.The time in therapeutic range (TTR) during oral warfarin administration was determined using the method of fraction of INRs in range in all patients. Embolic events were defined as clinical signs confirmed by computed tomography or angiography (neurological events).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using IBM SPSS (Version 27.0) (IBM Corporation, Armonk, NY, USA). Descriptive statistics are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or n (%), and categorical data as n (%). Paired sample t-tests were utilized to compare left atrial size pre- and postoperatively. A one-sided test with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULT","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Operative Data\u003c/h2\u003e \u003cp\u003eA total of 50 patients (16 men and 34 women, aged 54.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.71 years) participated in the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The preoperative data of these patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The average size of the left atrium was 52.08\u0026thinsp;\u0026plusmn;\u0026thinsp;10.60mm, and the ejection fraction was 57.74\u0026thinsp;\u0026plusmn;\u0026thinsp;7.28%. Long-lasting AF accounted for the most significant proportion at 52%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative Patient Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (68%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody surface area (m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.74\u0026thinsp;\u0026plusmn;\u0026thinsp;7.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.32\u0026thinsp;\u0026plusmn;\u0026thinsp;21.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiameter of the LA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.08\u0026thinsp;\u0026plusmn;\u0026thinsp;10.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eserum creatinine (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.32\u0026thinsp;\u0026plusmn;\u0026thinsp;21.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious incidence of stroke, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic lung disease, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNYHA class, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (68%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (32%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary heart disease, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious catheter ablation, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation type, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParoxysmal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLong-term persistence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (52%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eBMI, Body mass index; LVEF, left ventricular ejection fraction; LA: left atrium; NYHA, New York Heart Association.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean CPB duration was 136.94\u0026thinsp;\u0026plusmn;\u0026thinsp;38.43 minutes (range 70.00\u0026ndash;248.00 minutes), and aortic occlusion lasted on average 82.28\u0026thinsp;\u0026plusmn;\u0026thinsp;26.97 minutes (range 38.00\u0026ndash;144.00 minutes). Valvular surgeries included mitral valve procedures in 48 cases, aortic valve surgeries in 14, and tricuspid valve surgeries in 37. Mechanical valve replacements were performed in 28 cases, while biological valve replacements or valvuloplasty were carried out in 22. Other cardiac operations included CABG in five instances and closure of patent foramen ovale with patching in two (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Intraoperative TEE confirmed no residual flow between LAA and LA in all patients, and no remnants were observed in the closed LAA (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative Patient Data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral valve treatment, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBio Mitral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical Mitral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlasty Mitral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u0026rsquo;s classification, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVP, TVP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVR, AVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVR, TVP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVR, AVR, TVP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant CABG*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant CABG**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerfusion time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136.94\u0026thinsp;\u0026plusmn;\u0026thinsp;38.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross-clamp time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.28\u0026thinsp;\u0026plusmn;\u0026thinsp;26.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior Thrombotic location, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eMVP, mitral valve plasty; TVP, tricuspid valve plasty; MVR, mitral valve replacement; AVR, aortic valve replacement; LAA, left atrial appendage; LA, left atrium; CABG, coronary artery bypass grafting; * MVR, TVP, ** MVR, AVR, TVP.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLeft Atrial Appendage Closure Details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntraoperative TEE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative TEE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean follow-up, (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidual stump\u0026thinsp;\u0026le;\u0026thinsp;1 cm, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidual stump\u0026thinsp;\u0026gt;\u0026thinsp;1 cm, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eresidual shunts, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;5 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eTEE, transesophageal echocardiography; LA, left atrium.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Early clinical outcomes\u003c/h2\u003e \u003cp\u003eThere were no intraoperative or 30-day mortalities. Postoperative complications included atrioventricular block (n\u0026thinsp;=\u0026thinsp;2 [4%]), peri-prosthetic leak (n\u0026thinsp;=\u0026thinsp;2 [4%]), and secondary thoracotomy (n\u0026thinsp;=\u0026thinsp;1 [2%]). There were no incidences of renal insufficiency, cardiac tamponade, or stroke.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Medium-to-long-term TEE and TTE evaluation\u003c/h2\u003e \u003cp\u003ePatients were followed up for an average of 7.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.73 years, with TTE and TEE used to assess the results. During the medium-to-long-term follow-up,TEE identified one case of biological damage to the mitral valve. Postoperatively, nine (18%) patients exhibited LAA stumps, all measuring\u0026thinsp;\u0026lt;\u0026thinsp;1 cm; continuous flow between LAA and LA was observed in five (10%), with residual shunt areas ranging between 1\u0026ndash;2 mm. Four of the five patients with LAA closure failure underwent intraoperative mechanical valve replacement, three developed LAA thrombosis, and one who had biological valve replacement experienced LAA thrombosis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Follow-up Data\u003c/h2\u003e \u003cp\u003eAt the follow-up point, all 28 patients who underwent mechanical VR had successfully completed continuous anticoagulant therapy, with a mean time in TTR of their INR reaching 68.5%. The mean TTR of INR for the 22 patients who received Biologic VR / valvuloplasty and completed 6 months of warfarin-based anticoagulation therapy after surgery was found to be 70.8%. Notably, no bleeding complications were observed during warfarin administration among all patients.\u003c/p\u003e \u003cp\u003eNo stroke events were reported among patients with successful LAA closure. Among the five patients with closure failure, none of the four who underwent mechanical valve replacement experienced stroke events, whereas the patients who received biological valve replacement suffered a stroke 18 months postoperatively (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Follow-up Findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS-LAAO\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrent AF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStroke event\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMechanical VR (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuccess (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFailure (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBiologic VR /Valvuloplasty\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuccess (n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFailure (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eS-LAAO, Surgical left atrial appendage occlusion; AF, Atrial fibrillation; VR, valve replacement\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eIn patients with AF, intraoperative S-LAAO is pivotal in eliminating a thrombus-prone site. Extensive indirect evidence suggests that successful intraoperative S-LAAO effectively reduces the incidence of stroke events. Conversely, failure to close this structure may elevate the risk of strokes. Therefore, optimizing strategies to enhance the success rate of closure procedures becomes paramount.\u003c/p\u003e \u003cp\u003eIntraoperative and postoperative TEE revealed distinct reasons for the failure of various LAA closure techniques. Surgical excision, stapled excision, and AtriClip devices were more prone to failure due to a stump size\u0026thinsp;\u0026gt;\u0026thinsp;1 cm(\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Despite a stump size of \u0026lt;\u0026thinsp;1 cm(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), there remains an increased risk of postoperative thrombus formation, leading to stroke events. The advantage of the endocardial suture technique lies in its minimal residual stump presence; however, suboptimal overall success rates have been reported, with persistent residual shunting between LAA and LA being a common cause of failure. Remarkably, our average follow-up duration of 7.16 years demonstrated an exceptional success rate of 90%, significantly surpassing previous data.\u003c/p\u003e \u003cp\u003eFrom our perspective, key factors contributing to enhanced success rates encompass shortening and ensuring consistency in continuous stitching. A single suture can be replaced with a double suture to reinforce isolation. For LAA openings with irregular shapes, suturing should ensure smoothness on the left atrial side so that uniform force is exerted at each suture line position during atrial contraction. Compared to other techniques for closing the LAA, the endocardial suture technique offers distinct advantages such as procedural simplicity, minimal bleeding, and cost-effectiveness. Provided its success rate can be guaranteed, it represents a superior choice.\u003c/p\u003e \u003cp\u003eUnlike Katz et al.\u0026rsquo;s findings(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), persistent blood flow signals were not observed between LA and LAA through TEE following restoration of heart rhythm. Such continuous flow is hypothesized to manifest during the early postoperative period rather than intraoperatively. Among the five patients who experienced closure failure, residual shunt port lengths ranging from 0.1 to 0.3 mm were observed, indicating leakage between adjacent sutures.\u003c/p\u003e \u003cp\u003eFor patients with AF, long-term oral anticoagulation and LAA closure are considered distinct strategies to reduce stroke risk. Currently, there is insufficient robust evidence supporting the replacement of long-term anticoagulation with successful LAA closure(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e); therefore, the necessity for ongoing oral warfarin in patients with recurrent AF but successful LAA closure remains controversial. In this follow-up study, varying anticoagulation methods were employed based on the type of valve treated intraoperatively. Among patients not receiving long-term anticoagulation (n\u0026thinsp;=\u0026thinsp;21), 33.3% experienced recurrent AF; however, no strokes occurred during the follow-up. These findings suggest that continued oral anticoagulant therapy may be an unnecessary choice for individuals who have undergone successful S-LAAO, regardless of recurrent AF occurrence.\u003c/p\u003e \u003cp\u003eTheoretically, residual shunts between the LA and LAA may lead to blood stasis in the latter. Our central findings revealed that thrombus formation in the LAA occurred in 75% of the patients with closure failure, increasing the risk of thrombotic events upon detachment. Patients who experienced LAA closure failure without long-term anticoagulation suffered stroke events at 18 months postoperatively. While limited studies have explored the correlation between residual shunt diameter and stroke events, percutaneous LAA closure procedures offer a substantial dataset for analysis. One study demonstrated that patients with residual shunts\u0026thinsp;\u0026lt;\u0026thinsp;5 mm after LAA closure faced increased stroke risk(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). All observed residual shunts in our cohort were small (1\u0026ndash;3 mm), suggesting a higher likelihood of stroke events. Therefore, caution should be exercised before discontinuing warfarin anticoagulation in such cases. Therefore, prior to discontinuing warfarin, TEE should be employed to elucidate the status of LAA closure. In the event of unsuccessful closure, consider continuing warfarin anticoagulant therapy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e Limitations\u003c/h2\u003e \u003cp\u003eOur study has several limitations. First, over half of the patients declined to undergo follow-up TEE and were consequently excluded from the screening process. Hence, it is imperative to explore strategies for enhancing patient compliance with follow-up appointments or consider conducting cardiac computed tomography angiography (CTA) for those who refuse TEE examination. This approach would significantly augment the sample size and bolster data credibility. Second,the small size of our follow-up sample may limit its representativeness for the broader population. Moreover,our study exclusively focuses on patients with valvular disease; hence, caution is needed when extrapolating our findings to patients with other heart diseases who do not undergo postoperative anticoagulation.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003cp\u003eIntraoperative LAA closure is widely adopted in our center due to its simplicity, minimal bleeding risk, cost-effectiveness, and high success rate. Before discontinuing anticoagulation therapy, the TEE assessment should verify complete closure. For patients with confirmed LAA closure based on TEE, ongoing anticoagulant therapy may not be necessary; however, those who fail to achieve LAA closure should continue anticoagulation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eRetrospective ethical statement:\u003c/strong\u003e The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the ethics board of the Second Hospital of Jilin University (No. 2024 [076]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate statement: \u003c/strong\u003eThe study was conducted with the informed consent of the participants, who willingly signed the informed consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThis research was funded by the Health Commission of Jilin Province\u0026nbsp;(grant No. 2022LC113)\u0026nbsp;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declares that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThis research was funded by the Health Commission of Jilin Province\u0026nbsp;(grant No. 2022LC113)\u0026nbsp;.We thank Bullet Edits Limited for the linguistic editing and proofreading of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFootnote\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReporting Checklist: The authors have completed the STROBE reporting checklist.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOdutayo A, Wong CX, Hsiao AJ et al. Atrial fibrillation and risks of cardiovascular disease, renal disease, and death systematic review and meta-analysis. Bmj 2016 354 i4482.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark-Hansen J, Holme SJV, Irmukhamedov A, et al. Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: the LAACS randomized study. J Cardiothorac Surg. 2018;13:53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAryana A, Singh SK, Singh SM, et al. Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization. Heart Rhythm. 2015;12:1431\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitlock RP, Belley-Cote EP, Paparella D, et al. Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. N Engl J Med. 2021;384:2081\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149:e1\u0026ndash;156.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabra R, Gopinathannair R, Lakkireddy D. Left Atrial Appendage Occlusion During Cardiac Surgery: A 75-Year-Old Journey. J Am Heart Assoc. 2023;12:e030127.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSquiers JJ, Edgerton JR. Surgical Closure of the Left Atrial Appendage: The Past, The Present, The Future. J Atr Fibrillation. 2018;10:1642.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatz ES, Tsiamtsiouris T, Applebaum RM, et al. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol. 2000;36:468\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Fern\u0026aacute;ndez MA, P\u0026eacute;rez-David E, Quiles J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol. 2003;42:1253\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanderian AS, Gillinov AM, Pettersson GB, et al. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol. 2008;52:924\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamiano RJ Jr., Schwartz FH, Bailey MS, et al. The Cox maze IV procedure: predictors of late recurrence. J Thorac Cardiovasc Surg. 2011;141:113\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed A, Pothineni NVK, Singh V, et al. Long-Term Imaging and Clinical Outcomes of Surgical Left Atrial Appendage Occlusion With AtriClip. Am J Cardiol. 2023;201:193\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang Y, Hwang HY, Joo S, et al. Left atrial appendage elimination techniques: stapled excision versus internal suture obliteration. J Thorac Dis. 2021;13:6252\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee R, Vassallo P, Kruse J, et al. A randomized, prospective pilot comparison of 3 atrial appendage elimination techniques: Internal ligation, stapled excision, and surgical excision. J Thorac Cardiovasc Surg. 2016;152:1075\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHui DS, Alderson LJ, Lee R. Left atrial appendage thrombus after successful surgical exclusion on anticoagulation: a need for closer postintervention monitoring. Ann Thorac Surg. 2014;98:1478.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlkhouli M, Du C, Killu A, et al. Clinical Impact of Residual Leaks Following Left Atrial Appendage Occlusion: Insights From the NCDR LAAO Registry. JACC Clin Electrophysiol. 2022;8:766\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"atrial fibrillation, left atrial appendage closure, cardiac procedures, valvular heart disease","lastPublishedDoi":"10.21203/rs.3.rs-5448337/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5448337/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSurgical endocardial closure of the left atrial appendage (LAA) is reported to reduce the risk of stroke in patients with atrial fibrillation (AF). This retrospective study assessed the efficacy and safety of endocardial suture obliteration with medium-to-long-term follow-up.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 50 patients with valvular diseases and AF, treated from 2013 to 2018, were included in the analysis. All underwent heart valve surgery, the Cox-Maze IV procedure, and LAA closure using the endocardial suture obliteration technique. Intraoperative transesophageal echocardiography (TEE) was performed to assess the LAA closure outcomes. Closure failure was defined as a remnant LAA (\u0026gt;\u0026thinsp;1 cm) or persistent flow between the left atrium (LA) and LAA. Patients were followed up for an average of 7.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.73 years, with transthoracic echocardiography (TTE) and TEE used to assess the results.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIntraoperative TEE revealed no remnants of the LAA or persistent flow in any patient post-closure. None of those monitored postoperatively with TEE exhibited a remnant LAA\u0026thinsp;\u0026gt;\u0026thinsp;1 cm; however, 5 (10%) patients had persistent flow between the LA and LAA. Of these five patients with closure failure, four (75%) presented with thrombus in the LAA stump, and one experienced a stroke event.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur center has widely adopted the intraoperative closure of the LAA due to its simplicity, minimal bleeding risk, cost-effectiveness, and high success rate. For patients with confirmed LAA closure based on TEE evaluation, continued use of anticoagulant drugs may not be necessary.\u003c/p\u003e","manuscriptTitle":"Medium-to-Long-Term Success Rate of Left Atrial Appendage Closure Using Endocardial Sutures and Postoperative Anticoagulant Strategies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 18:39:18","doi":"10.21203/rs.3.rs-5448337/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"305d2cb5-7c76-4636-9b5f-349a9394ca86","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-24T11:55:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-19 18:39:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5448337","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5448337","identity":"rs-5448337","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}