Convergent Ablation and Left Atrial Appendage Exclusion: How to Do It Through a Unique Left Thoracoscopic Approach?

LEFT ATRIAL APPENDAGE EXCLUSION IS AN INDEPENDENT PREDICTOR OF LATE SURVIVAL IN PATIENTS UNDERGOING MITRAL VALVE SURGERY

Reply to the Editor

Impact of Left Atrial Appendage Exclusion on Cardiovascular Outcomes in Patients With Atrial Fibrillation Undergoing Coronary Artery Bypass Grafting (From the National Inpatient Sample Database)

To the Editor: With great interest we read the article by Onalan et al about left atrial appendage (LAA) exclusion for stroke prevention in nonrheumatic atrial fibrillation (AF).1 We share the author’s concerns about the hazards of this procedure and would like to emphasize additional arguments. There is no evidence that thromboembolism in AF exclusively derives from LAA thrombi detected by transesophageal echocardiography. The prevalences (4% to 21%) of LAA-thrombi were found in studies of acutely sick patients, patients before cardioversion, cardiac surgery or after recent embolism. Contrarily, when prospectively investigating clinically stable outpatients with AF and no recent embolism by transesophageal echocardiography, the prevalence of LAA thrombi was only …

Pulmonary Artery Perforation by Plug Anchoring System After Percutaneous Closure of Left Appendage

Background/Objectives: Persistent and long-standing persistent atrial fibrillation (AF) presents a therapeutic clinical challenge balancing complex rhythm management with a heightened stroke risk. The left atrial appendage (LAA) is the primary source of thromboembolisms in these patients. This study evaluated the safety and efficacy of combining LAA exclusion with Convergent Hybrid Ablation for stroke prevention and rhythm control in a refractory patient cohort. Methods: A single-center observational cohort study was conducted including 28 patients with symptomatic persistent or long-standing persistent AF. The cohort was highly refractory, with 82.1% having failed at least one endocardial catheter ablation. The hybrid procedure consisted of sub-xiphoid epicardial ablation, thoracoscopic LAA exclusion (AtriClip), and endocardial catheter ablation. Safety and efficacy were assessed at 3 months and 12 months. Results: LAA exclusion was successfully performed in 96.4% of patients. The peri-operative safety profile was acceptable, with zero procedure-related strokes or deaths. At the 12-month follow-up, the rate of stroke or any other major adverse events was at 0.0%. Freedom from AF was 75.0%, shown by a 12-lead electrocardiography (ECG). Freedom from any atrial arrhythmia off anti-arrhythmic drugs (AADs) was achieved in 50.0% of patients. A total of 32.1% of the cohort required catheter ablation within 12 months to maintain sinus rhythm as part of the hybrid treatment. Conclusions: Concomitant LAA exclusion during Convergent Hybrid Ablation is a safe procedure with a high clinical success rate in maintaining sinus rhythm in a highly complex AF patient group. While no thromboembolic events were observed at 12 months, larger studies with longer follow-up are needed to confirm the potential for long-term stroke risk reduction. The findings suggest that for many patients, the hybrid procedure should be viewed as part of a multi-step strategy often requiring endocardial “touch-up” ablation.

The objective of this study was to evaluate the impact of left atrial appendage (LAA) exclusion on short-term outcomes in patients with atrial fibrillation undergoing isolated coronary artery bypass graft surgery. We queried the 2010 to 2014 National Readmissions Database for patients who underwent coronary artery bypass graft repair with and without LAA ligation by using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification: 36.1xx). Only patients with a history of atrial fibrillation were included in our analysis. The primary outcome of our study was 30-day readmissions following discharge. Secondary outcomes were in-hospital mortality and stroke. To assess the postoperative outcomes, we used multivariate logistic regression models to adjust for clinical and demographic covariates. In total, we analyzed 253 287 patients undergoing coronary artery bypass graft surgery, 7.0% of whom received LAA closure. LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P<0.0001) and acute kidney injury (21.8% versus 18.5%, P<0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with a nonsignificant reduction in stroke (7.9% versus 8.6%, P=0.12), no difference in in-hospital mortality (2.2% versus 2.2% P=0.99), and a greater risk of 30-day readmission (16.0% versus 9.6%, P<0.0001). After covariate adjustment, LAA ligation remained a significant predictor of 30-day readmission (odds ratio, 1.640 [95% CI, 1.603-1.677], P<0.0001). LAA exclusion during isolated coronary artery bypass graft surgery in patients with atrial fibrillation is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.

The purpose of this study was to determine whether surgical left atrial appendage (LAA) exclusion performed during mitral valve surgery is associated with a reduction in cerebrovascular events in patients with atrial fibrillation. We retrospectively studied patients with atrial fibrillation who underwent mitral valve surgery from 1/1/2001 through 12/31/2014. We screened 1352 patients using ICD-9 codes and included 281 patients in the study. The primary end point was a composite of strokes and transient ischemic attacks occurring within 5years after surgery. Secondary end points were stroke, transient ischemic attack, and all-cause mortality. The LAA exclusion group (n = 188) had a lower prevalence of female gender, hypertension, and diabetes mellitus compared with the non-LAA exclusion group (n = 93). The CHA2DS2VASc scores were comparable between groups (2.6 vs 2.9, P = .11), as was anticoagulant use (82.4% vs 85.0%, P = .60). Concomitant surgical ablation was performed in 73.9% of patients who underwent LAA exclusion. Nine cerebrovascular events occurred in the LAA exclusion group and 13 in the non-LAA exclusion group (HR 0.30 [0.12-0.75], P = .01). There was no difference in all-cause mortality between groups. On multivariate analysis of the primary end point of strokes or transient ischemic attacks, significant variables were LAA exclusion (HR 0.31 [0.12-0.76], P = .01) and CHA2DS2VASc score (HR 1.44 [1.11-1.87], P = .006). The benefit of LAA exclusion was detected only when performed together with surgical ablation (HR 0.27 [0.09-0.72], P = .01). LAA exclusion was associated with fewer cerebrovascular events. However, this benefit was seen only with concomitant surgical ablation.

Introduction: Management of patients with long standing persistent atrial fibrillation (LSPAF) presents a clinical challenge. Hybrid convergent ablation has been shown to have superior efficacy compared to endocardial ablation in patients with LSPAF. However, real world outcomes of concomitant hybrid convergent ablation and left atrial appendage (LAA) exclusion with an atrial clip are sparse. Hypothesis: To evaluate effectiveness of concomitant hybrid convergent ablation and LAA clipping in patients with long standing persistent AF (LSPAF). Methods: We conducted a retrospective analysis of all patients with LSPAF that underwent hybrid convergent ablation (surgical ablation plus endocardial catheter ablation) and LAA clipping at our institution. All patients had implantable cardiac devices (27.9% CIED and 81.4% ILR). ILRs were programmed to detect &gt;6-minute episodes of AF. Primary end point was recurrence of AF at 12 months. Results: A total of 43 patients underwent hybrid convergent ablation and LAA exclusion from 2019-2020. Mean age of the cohort was 64.9 + 8.9 years and 62.8% were male. 61.9% patients had previous AF catheter ablation and majority (84%) were on anti-arrhythmic drugs (AAD). LAA clipping was performed in all patients with a median clip size of 45. Mean time between the surgical and endocardial catheter ablation procedure was 2.6 + 1.7 months. All patients were continued on AAD following the hybrid procedure. Overall AF free survival on continued anti-arrhythmic drugs at 12 month follow up was 68.3%. Conclusions: Concomitant hybrid convergent ablation and LAA exclusion with an atrial clip provides reasonable long term AF free survival in patients with LSPAF.

Postoperative Transesophageal Echocardiographic Evaluation of Surgical Left Atrial Appendage Exclusion: Characterization and Predictors of Success

B-PO03-157 PROPHYLACTIC LEFT ATRIAL APPENDAGE EXCLUSION IN PATIENTS UNDERGOING CARDIAC SURGERY: RESULTS OF PROSPECTIVE, MULTICENTER, RANDOMIZED ATLAS TRIAL

Cardiovascular Outcomes With Surgical Left Atrial Appendage Exclusion in Patients With Atrial Fibrillation Who Underwent Valvular Heart Surgery (from the National Inpatient Sample Database)

This study aimed to evaluate the role of surgical left atrial appendage (LAA) exclusion in the prevention of stroke after mitral valve replacement (MVR). We retrospectively reviewed clinical data of 860 patients who received MVR in our center from January 2008 to January 2013. The patients were randomly assigned to two surgical groups, namely LAA exclusion group (n = 521) and LAA nonexclusion group (n = 339) according to whether concurrent surgical exclusion of the LAA was to be undertaken or not before surgery in a blind fashion. MVR was performed by two experienced surgeons. The LAA was explored during the operation and mural thrombus removed in all cases. The LAA was left intact in nonocclusion group whereas the neck of the LAA was closed with a two-layer continued suture in exclusion group. The incidence of early postoperative ischemic stroke between the two groups was compared. The patients' age was 53 ± 12 years, with 48.1% male and 67.9% with rheumatic disease. Mural thrombosis was seen in 18.8% of the patients and atrial fibrillation (AF) coexisted in 62.4%. All operations were successfully performed and no difference was noted in in-hospital mortality, re-exploration for bleeding, and other major complications between the two groups. The incidence of ischemic stroke in LAA exclusion group was significantly lower than in nonexclusion group (0.6% vs. 2.7%, p = .011). The subgroup multivariate analysis showed that LAA exclusion significantly reduced the risk of postoperative stroke in patients with AF (odds ratio [OR] = 0.070, 95% confidence interval [CI]: 0.006-0.705, p = .025) but not in non-AF patients (OR = 1.902, 95% CI: 0.171-21.191, p = .601). Concurrent LAA exclusion during MVR is a safe and effective way to reduce postoperative ischemic stroke, particularly in patients with AF.

Commentary: The appendage strikes back: The last surgeon

Highlights. Stroke prevention in patients with atrial fibrillation is extremely important and difficult. Lifelong anticoagulant therapy is not always an effective way of preventing thrombosis in the left atrial appendage in this group of patients. In this regard, one of the most urgent problems of modern surgical arrhythmology and cardiac surgery is the search for new open and minimally invasive surgical methods of excluding the left atrial appendage from the blood flow.Aim. To investigate the safety and efficacy of using the left atrial appendage stapler for video-guided thoracoscopic ablation (TSA) of non-valvular atrial fibrillation (AF).Methods. The retrospective, single-center study included 100 patients with non-valvular AF who underwent video-guided thoracoscopic ablation of AF with single-stage left atrial appendage exclusion using an Endo GIA stapler (Medtronic, Minneapolis, Minnesota, USA).Results. The mean age of the patients was 56,2±8,8 years, the majority of the patients (73 patients, 73%) were male. Patients with persistent 50 (50%) AF and longstanding AF 50 (50%) were included in the study. The duration of atrial fibrillation was 4 (1,7–7) years. The median CHA2DS2-VASc and HAS-BLED scores were 2 (1–1,5) and 1 (0-1), respectively. The mean anticoagulation therapy-to-ablation time was 4,2±1,9 years. Thirty-eight (38%) patients were prescribed warfarin preoperatively. The completeness of left atrial appendage (LAA) exclusion was confirmed by intraoperative transesophageal echocardiography. The average length of the staple lines was 48 (35–75). A single left atrial appendage exclusion was performed using a 60 mm staples. In 12 (12%) patients, stapler exclusions were performed using two 45 mm staples due to insufficient staple length. None of the patients had ruptures, punctures along the staple lines or rupture of the surrounding epicardial tissue. Anticoagulant therapy was discontinued 6 months after TSA in 70 (70%) patients with sustained sinus rhythm observed on 24-h Holter Monitoring, satisfactory CHA2DS2-VASc scores and after confirmation of absence of left atrial thrombus by transesophageal echocardiography and contrast-enhanced MSCT. No strokes were reported within 1,2±0,7 years after discontinuing anticoagulation therapy.Conclusion. Exclusion of LAA using a stapler for TSA is a highly effective and safe technique for patients with non-valvular atrial fibrillation compared to alternative methods of excluding the LAA from the systemic blood flow.