Predictors of incomplete ligation (isolation) of the left atrial appendage during off-pump coronary artery bypass grafting according to intraoperative transesophageal echocardiography

Objective: To reveal predictors of incomplete epicardial ligation (isolation) of the left atrial appendage (LAA) during off-pump coronary artery bypass grafting according to intraoperative transesophageal echocardiography (TEE). Material and methods: 37 patients with coronary heart disease (with arterial hypertension and atrial fibrillation in all cases) underwent epicardial LAA ligation during off-pump coronary artery bypass grafting. Mean age of patients was 58.7 ± 7.7 years (38-74 years), 35 (95%) of them were male. Echocardiography utilized iE33 (Philips, Netherlands) with a 1-5 MHz sector probe and a 2-7 MHz transesophageal sector probe. Pre- and post-LAA ligation intraoperative TEE monitoring performed in all cases. In pre-LAA ligation examination, width of LAA ostium, LAA length, width of LAA ostium/LAA length ratio, LAA area, LAA and LAA ostium blood flow, and LAA blood flow velocity were assessed. In post-LAA ligation examination, completeness of ligation was assessed in color Doppler ultrasound. If the presence of communication between LAA and LA was revealed, LAA ligation considered as incomplete and diameter of communication (width of LAA ostium after ligation) was measured. Results: In intraoperative TEE incomplete LAA ligation was detected in 10 (27%) patients. Significant differences of width of LAA ostium (P = 0.001), width of LAA ostium/LAA length ratio (P = 0.03), and LAA area (P = 0.005) between patients with complete and incomplete ligation were found when analyzing the data of pre-ligation intraoperative TEE. Width of LAA ostium ≥18.4 mm (sensitivity - 60.0%, specificity - 100.0%), width of LAA ostium/LAA length ratio ≥0.8 (sensitivity - 30.0%, specificity - 92.6%), and LAA area ≥4.21 cm2 (sensitivity - 60.0%, specificity - 100.0%) can be considered as the predictors of incomplete LAA ligation. Conclusion: The incidence of incomplete epicardial LAA ligation during off-pump coronary artery bypass grafting is 27%. A number of intraoperative TEE criteria for incomplete LAA ligation prognosis with ultra-high specificity were obtained, but sensitivity was only 30.0-60.0%.

intraoperative transesophageal echocardiography, ligation of the left atrium appendage, incomplete ligation of the left atrial appendage (unsuccessful left atrial appendage closure), off-pump coronary artery bypass grafting

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