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Eur J Cardiothorac Surg 2000;18:627
© 2000 Elsevier Science NL

Letter to the Editor

Reply to C. Stöllberger, G. Ernst and J. Finsterer

St. Francis Hospital, 3300 South 16th Street, Milwaukee, WI 53215, USA

Received 5 July 2000; accepted 22 August 2000.

Present address: 350 Bishops way, Suite No. 202, Brookfield, WI 53005, USA. Tel.: +1-262-938-9880; fax: +1-262-938-9885
e-mail: life{at}johnsonheartcare.com

Some physiological roles for the LAA have been identified, and some are referenced in the article. The LAA varies in size in different animals. The goat LAA is of moderate size, and we selected that animal for the study. I can't comment on the relative size of the guinea pig appendage. It is possible the function would vary in animals. Total obliteration of the LAA has been performed by numerous surgeons for decades. It has usually been done in association with mitral surgery. We are not aware of one single clinical situation reported in which LAA removal produced a major or even moderately severe problem. In the surgery proposed by us, the major purpose is to obliterate the blind pouches which are almost certainly the sources of clots. The border between the appendage and the atrium cannot be accurately defined in surgery. A gentle bulging appendage, free of blind pouches, is left after the stapling procedure. What percentage of the appendage remains cannot be determined (see photo in original article). In a few patients, after the appendage is clamped, the blood distal to the clamp has been aspirated and then the appendage filled with saline. Usually 3 to 5 cc of saline totally fills the appendage distal to the clamp. It is doubtful that a clinical situation would occur in which this additional atrial volume would alter a critical situation. While guinea pigs may have a much better output with the appendage, the few human studies performed showed appendectomy caused no change in output or blood pressure, and about 1 mmHg change in LA pressure. The pulmonary venous flow velocity actually increased with appendage ligation, perhaps something that might help prevent clots (see Ref. 21 in original paper) If guinea pigs were in AF, I doubt that an appendage removed would have any effect on output.

The extensive bilateral atrial trauma associated with the maze procedure can hardly be compared with the partial appendage appendectomy we perform. The residual appendage we always leave behind must surely be capable of producing some natriuretic factor (NF). Total appendage obliteration, commonly done for decades, has failed to produce a major syndrome of ANF deficiency. It is unlikely that partial appendectomy will cause an ANF deficiency syndrome.

Without a doubt, there is a mild physiologic function of the LAA. How much this is altered by partial removal cannot be determined. I do not doubt that someday the very first case will be described in which a deficiency of ANF caused a major problem. Meanwhile hundreds of thousands of people in Europe and the USA suffer major strokes every year because of clots originating from the appendage. For us, the choice of which approach to take is clear.

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