Iatrogenic Atrial Dysfunction After Prophylactic Left Atrial Appendage Exclusion: A Proposed Post-Procedural Atrial Phenotype

Cardiac surgeons increasingly exclude the left atrial appendage during operations in patients who have never had atrial fibrillation, often because the appendage is accessible and presumed expendable. This Europace Viewpoint challenges that reflex by proposing “iatrogenic atrial dysfunction syndrome” (IADS)—a testable post-procedural phenotype, not yet a validated diagnosis. In a heart in sinus rhythm, the appendage is electrically active and contributes to atrial compliance, reservoir function, pressure buffering, and neurohormonal regulation. Its abrupt exclusion may remove these functions precisely when the atrium is stressed by inflammation, fluid shifts, ischemia-reperfusion, and autonomic activation. The result, in susceptible patients, may be postoperative atrial fibrillation, altered atrial mechanics, and uncertainty about anticoagulation, rhythm surveillance, and residual stroke risk—particularly when closure is incomplete. The message is not that appendage exclusion is wrong, but that prophylactic exclusion should require an indication, documentation, and follow-up. Surgeons should not routinely ligate every appendage simply because it is visible.