Concomitant left atrial appendage exclusion during cardiac surgery: a single-center case series on technique profile, residual flow, and early safety

Concomitant left atrial appendage exclusion is increasingly performed during cardiac surgery in patients with atrial fibrillation. However, real-world data on procedural variations, closure integrity, and early safety are limited. We retrospectively reviewed 86 patients with atrial fibrillation who underwent concomitant left atrial appendage exclusion during cardiac surgery at a single center between 2012 and 2025. Nineteen patients underwent left atrial appendage occlusion using suture-based techniques or a closure device, and 67 underwent left atrial appendage resection with closure using sutures or a stapler. Residual flow was assessed using intraoperative transesophageal echocardiography, and outcomes were evaluated during follow-up. Patients in the occlusion group more often had longer atrial fibrillation duration, vitamin K antagonist use, and previous cardiac surgery. Mitral valve procedures were more frequently combined with occlusion, whereas maze ablation was more common in the resection group. Intraoperative residual flow was detected in three patients (16%) after occlusion and in none after resection. Both approaches showed favorable early safety, with no 30-day mortality and low reoperation rates due to bleeding. Differences in sinus rhythm and anticoagulation at three months were observed, but were likely influenced by concomitant maze procedures. Differences in long-term survival were also observed but should be interpreted cautiously because of baseline imbalances and unequal follow-up duration. In this single-center retrospective case series, suture-based occlusion was associated with residual flow in a subset of patients, whereas no residual flow was detected after resection using intraoperative echocardiography. Both approaches showed acceptable early safety. Larger multicenter studies with standardized follow-up imaging are needed to clarify closure durability and the long-term clinical outcomes.