Clipping It in the Bud
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Information about a real patient is presented in stages (boldface type) to expert clinicians (Drs Murthy and Yang), who respond to the information and share their reasoning with the reader (regular type). A discussion by the authors follows.
Patient presentation: Mr H is a 50-year-old male admitted in 2013 with methicillin-sensitive Staphylococcus aureus bacteremia and aortic valve endocarditis. Other medical history includes hypertension, paroxysmal atrial fibrillation, end stage renal disease, undergoing hemodialysis through a left upper extremity arteriovenous fistula, and stroke. He underwent intraoperative pulmonary vein isolation, epicardial left atrial appendage closure using a 50-mm AtriClip device, and bioprosthetic aortic valve replacement at an outside hospital.
Dr Yang: Because 90% of thrombi in nonvalvular atrial fibrillation originate in the left atrial appendage (LAA), this structure has emerged as a therapeutic target to reduce the risk of cardioembolic stroke. Mr H has a history of labile international normalized ratios, a HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition [anemia], Labile INR, Elderly [age>65], Drugs/Alcohol concomitantly) score of 4, and prior stroke while on anticoagulation, thereby warranting consideration of alternative therapies to warfarin for stroke protection, if feasible. The 2014 American College of Cardiology/American Heart Association guideline statement on atrial fibrillation makes a class IIb recommendation for surgical occlusion of the LAA during other cardiac surgeries. Despite this guideline, surgical occlusion with a prosthetic device is not advisable in this patient because of active endocarditis and the risk for recurrent infection in the future. Moreover, patients with valvular heart surgery and those with active systemic infection were excluded in the pivotal EXCLUDE trial, which studied the safety and efficacy of the AtriClip placement.1 A suture-based LAA occlusion strategy to minimize implanted prosthetic material would have been preferred.
The underlying rationale that exclusion of the thrombogenic LAA may reduce short- …