337-I * THORACOSCOPIC LEFT ATRIAL APPENDECTOMY

Abstract

Objectives: In patients with non-rheumatic atrial fibrillation, the most common place for thrombosis is the left atrial appendage (LAA). The efficacy of stroke prevention with oral anticoagulant therapy (OAC) has been proved, but there are patients who are not candidates for long-term OAC, namely patients with a high risk of bleeding complications or previous haemorrhagic stroke. In those patients, percutaneous closure of the LAA has been demonstrated to be safe and efficacious in preventing cardioembolic events. However, some LAAs are too large or too fragile and they may not be suitable for occlusion. Methods: We present a film showing videothoracoscopic LAA excision in an 82-year-old male patient with lone atrial fibrillation, in whom the need to suppress OAC became obvious after an intracerebral haemorrhagic event. Percutaneous closure of LAA also failed because an additional LAA lobe precluded tight occlusion. Results: Following right selective pulmonary intubation, the patient was placed in a right anterolateral decubitus position. Transoesophageal echocardiography confirmed the absence of LAA thrombus. Three thoracoscopic incisions were made to introduce the video-assisted thoracoscopic instruments. The pericardial cavity was entered 1 cm above the phrenic nerve and the pericardial incision was enlarged to visualize the LAA. Then, a gentle traction was performed to show the appendiceal base where a row of staples was placed. The duration of the procedure was 40 min and the patient was discharged after four days without postoperative complications. Conclusions: This approach demonstrated feasibility, safety and effectiveness and should be considered as a possible alternative to percutaneous closure of the LAA. However, its effect on long-term prevention of stroke needs to be evaluated.