Should the Left Atrial Appendage Always be Removed in Mital Valve Surgery? In Search of a Perfect Outfit

Atrial fibrillation is the most common arrhythmia in worldwide. The left atrial appendage morphology with long body and narrow base, blood stasis and atrial fibrillation increase thrombi formation. Cardioembolic strokes are 17.9-fold more frequent in non-valvular atrial fibrillation patients than those without atrial fibrillation. The efficacy of chronic anticoagulation therapy to prevent ischemic strokes in atrial fibrillation is well established. Adjusted-dose warfarin reduces stroke by 60% and death by 25% compared with no antithrombotic treatment. Introduction of NOACs agents has help to increase the proportion of atrial fibrillation patients receiving anticoagulant therapy. However, despite demonstrated efficacy and professional guideline recommendations, oral anticoagulation treatment rates in patients with atrial fibrillation are generally below 60%. Left atrial appendage occlussion has now become the most preferred method of choice for reducing the possibility of stroke in non-valvular atrial fibrillation, especially in cases in which oral anticoagulant therapy is contraindicated. It is well established the usefulness of the left atrial appendage removal in patients with rheumatic mitral valve disease and atrial fibrillation. Theoretically, removal of the left atrial appendage in patients with mitral valve disease in normal sinus rhythm could have several advantages, taking into account that 26% of mitral valve operations exhibits postoperative atrial fibrillation. Nevertheless, further randomized studies are needed to answer if LAA should be removed in all cases of MV surgery.