Left Atrial Appendage Exclusion Research Articles

Temporal trends in the utilization, costs, and outcomes of concomitant left atrial appendage closure across a statewide collaborative

ObjectiveWith the rising incidence of atrial fibrillation, left atrial appendage closure (LAAC) at the time of cardiac surgery remains an important adjunct. The present study characterized trends, associated resource utilization, and potential disparities in the use of left atrial appendage exclusion. MethodsUsing a Society of Thoracic Surgeons regional academic collaborative database, we queried all adult patients undergoing coronary and valve procedures with concomitant LAAC between 2015 and 2021. Trends in LAAC, as well as the technique for closure, were evaluated. Multilevel hierarchical logistic modeling was applied to delineate factors associated with LAAC, accounting for patient and operative characteristics. Generalized linear models were developed to perform risk-adjusted incremental cost analysis. ResultsOf the 8699 patients who met the study criteria, 1377 underwent left atrial appendage closure. Over the study period, the annual rate of LAAC increased from 16.7% to 30.8% (P < .001). LAAC patients were older, but less commonly insulin-dependent diabetics or on dialysis. Female sex, redo, and urgent operative status had lower risk-adjusted odds of LAAC. Although LAAC was associated with longer bypass time, there was no significant association with 30-day mortality or 30-day readmission. LAAC was associated with an incremental increase in adjusted costs by $10,602 (95% confidence interval, $4078-$17,126). ConclusionsRates of LAAC are increasing but less common among female patients, as well as those requiring urgent/emergent interventions. LAAC did not significantly impact short-term mortality. Our results suggest that LAAC may be a high-value intervention among patient populations that have the greatest potential to derive its benefits.

Innovative Surgical Left Atrial Appendage Closure Technique: Early Experience of Inverted Spiral Closure Technique.

Simultaneous closure of the left atrial appendage (LAA) during cardiac procedures has become a common preventive measure against cardiogenic embolic events associated with atrial fibrillation. However, this strategy encounters limitations during minimally invasive mitral valve surgery through a right minithoracotomy because access to the LAA is limited. The use of endocardial sutures for surgical exclusion of the LAA is also well established but has a notable rate of closure failure. We introduced a new surgical LAA closure technique called the inverted spiral closure technique (ISCT). Between July 2020 and August 2021, 26 patients underwent LAA closure with ISCT concomitant to mitral valve surgery in our hospital. Early postoperative outcomes and any stroke or thromboembolic event during the follow-up were evaluated. Transthoracic or transesophageal echocardiography (TEE) was used to assess LAA patency. The ISCT procedure was performed successfully in all cases. No significant persistent flow between the left atrium and LAA was observed on intraoperative TEE. During a median follow-up of 1.1 years, no patients experienced stroke, myocardial infarction, or death. Postoperative echocardiography showed no significant residual flow within the LAA. One patient was incidentally found to have recanalization between the left atrium and LAA several months after surgery on an enhanced computed tomography scan during coronary evaluation. The ISCT can be performed reliably through the same left atriotomy for mitral valve surgery and is a useful and effective technique for surgical LAA exclusion. There are still not enough patients and modalities for postoperative evaluation.

Commentator Discussion: Left atrial appendage exclusion during open cardiac surgery in patients without atrial fibrillation reduces 4-year ischemic stroke and mortality

Commentator Discussion: Left atrial appendage exclusion during open cardiac surgery in patients without atrial fibrillation reduces 4-year ischemic stroke and mortality

Left atrial appendage exclusion during open cardiac surgery in patients without atrial fibrillation reduces 4-year ischemic stroke and mortality

ObjectiveThis study assessed the influence of surgical left atrial appendage exclusion (LAAE) during cardiac surgery in patients with no preoperative history of atrial fibrillation (AF). MethodsReal World Data Insights, an all-payers’ claims database, with approximately 90% Medicare patients was utilized. Patients with no preoperative history of AF (older than age 65 years) undergoing open coronary artery bypass or valve procedures with/without concomitant surgical LAAE with an epicardial clip between 2015 and 2020 and a minimum of 2-year follow-up were included. Inverse probability treatment weighting and logistic regression were used. ResultsOpen coronary artery bypass represented 48.8% (n = 29,954) and valve 51.2% (n = 31,466) of procedures after adjustment. Thirty-day postoperative AF was present in 12.2% patients (n = 175) for LAAE and 5.8% (n = 3485) for no-LAAE (P < .01). By day 90 after surgery, rates of new AF were similar between groups through 4-year follow-up. During 4 years of follow-up more patients received oral anticoagulation with LAAE (P < .01). LAAE had 28% lower adjusted ischemic stroke odds (odds ratio, 0.72; 95% CI, 0.53-0.98; P = .02) and 34% lower adjusted all-cause mortality (odds ratio, 0.66; 95% CI, 0.52-0.85; P < .01). In patients who developed postoperative AF, LAAE + oral anticoagulation showed 74% lower odds of adjusted ischemic stroke (odds ratio, 0.26; 95% CI, 0.10-0.70; P = .01) and 58% lower odds of adjusted all-cause mortality (odds ratio, 0.42; 95% CI, 0.18-1.01; P = .05) than no-LAAE + oral anticoagulation therapy alone. ConclusionsLAAE during open cardiac surgery in patients without AF was safe, associated with higher postoperative AF, and lower ischemic stroke and all-cause mortality. Randomized controlled studies are ongoing in a similar population.

Device-Assisted Left Atrial Appendage Exclusion: From Basic Sciences to Clinical Applications.

Device-assisted left atrial appendage exclusion plays a crucial role in the prevention of fatal ischemic complications in patients with atrial fibrillation and contraindications to anticoagulation treatment. Various devices with different safety profiles and device-related complications are available in daily practice to perform this procedure. In this review, the anatomy, physiology, and functions of the left atrial appendage were detailed, and all available devices used for epicardial and endocardial exclusion of the left atrial appendage and their clinical outcomes were discussed. Future research should aim to further investigate the long-term effects of left atrial appendage exclusion on body homeostasis, blood coagulation, and cardiac function.

Outcomes of hybrid surgical ablation and concomitant left atrial appendage exclusion in long-standing persistent atrial fibrillation.

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-only ablation. However, data on concomitant left atrial appendage (LAA) management along with hybrid ablation is sparse. We aimed to evaluate the effectiveness of concomitant hybrid convergent ablation and LAA clipping in patients with LSPAF. We conducted a retrospective analysis of all patients with LSPAF who underwent hybrid surgical ablation with LAA clipping at our institution. The primary endpoint was a recurrence of atrial arrhythmias at 12 months. Further, the durability of surgical left atrial posterior wall ablation was examined during the endocardial catheter ablation using standing electrophysiological criteria. A total of 79 patients were included. Mean age was 63.5 ± 9.6 years, and 71% were males. LAA clipping was performed in 99% of patients. The mean time between the surgical and endocardial stages of the procedure was 2.6 ± 1.7 months. Persistent posterior wall activity was observed in 34.2% (n = 27/79) patients during the endocardial phase of the procedure. Cardiac implantable electronic device was used in 74% of patients for monitoring of recurrence of atrial fibrillation (AF). The primary effectiveness of AF freedom at 12 months was 73.8% (45/61). Over a 12-month follow-up period, 11.4% (9/79) of patients required repeat catheter ablation, of which 88.9% (8/9) had evidence of persistent posterior wall activity. Concomitant hybrid convergent ablation and LAA exclusion with an atrial clip provides reasonable long-term AF-free survival in patients with LSPAF. Persistent posterior wall activity is seen commonly in patients presenting with recurrent AF following hybrid convergent AF ablation.

The left atrial appendage exclusion for prophylactic stroke reduction (leaaps) trial: rationale and design

IntroductionLeft atrial appendage exclusion (LAAE) has been shown in randomized trials to reduce ischemic stroke risk in patients undergoing cardiac surgery with known atrial fibrillation (AF). Many patients undergoing cardiac surgery without pre-existing AF are at risk of stroke and may benefit from LAAE. MethodsLeft Atrial Appendage Exclusion for Prophylactic Stroke Reduction (LeAAPS) is an international, prospective, randomized, multicenter, blinded trial evaluating the effectiveness of LAAE in preventing ischemic stroke or systemic embolism in patients undergoing cardiac surgery at increased risk of AF and ischemic stroke. The trial will enroll 6500 patients at increased risk of stroke in whom a cardiac surgery is planned at 250 sites worldwide. Eligible patients are ≥18 years old, have no pre-existing AF but are at increased risk for AF and stroke (based on age, CHA2DS2-VASc score, left atrium size or brain natriuretic peptide). Patients are randomized 1:1 to receive either LAAE with AtriClip or no LAAE during cardiac surgery. Healthcare providers outside of the operating room and the patient will be blinded to allocation. The primary effectiveness endpoint is the first occurrence of ischemic stroke, systemic arterial embolism, or surgical or endovascular LAA closure. The powered secondary effectiveness endpoint is ischemic stroke or systemic arterial embolism. The primary safety endpoint is the occurrence of one of the following events (through 30 days): pericardial effusion requiring percutaneous or surgical treatment, peri-operative major bleeding, deep sternal wound infection, or myocardial infarction. Other endpoints include mortality, rehospitalizations, clinically diagnosed AF, transient ischemic attack, and cognitive and quality of life assessments. Follow-up is every 6 months for a minimum of 5 years; primary analysis occurs when 469 patients have had an ischemic stroke or systemic embolism. ConclusionThe results of the LeAAPS trial will demonstrate whether LAAE with AtriClip at the time of other routine cardiac surgery reduces stroke or systemic arterial embolism during long-term follow-up in patients at high risk of stroke without pre-existing AF. Trial RegistrationClinicalTrials.gov, Identifier: NCT05478304, https://clinicaltrials.gov/study/NCT05478304?term=%20NCT05478304&rank=1

Stroke Prevention With Prophylactic Left Atrial Appendage Occlusion in Cardiac Surgery Patients Without Atrial Fibrillation: A Meta-Analysis of Randomized and Propensity-Score Studies.

The role of left atrial appendage occlusion (LAAO) in patients without previous atrial fibrillation (AF) is not established. This meta-analysis was conducted on patients with normal sinus rhythm who underwent cardiac surgery, with and without concomitant LAAO, to evaluate its effect on the incidence of cerebrovascular accidents (CVAs). A systematic review was conducted from inception until December 2023 for randomized and propensity-score studies comparing CVA in patients without AF undergoing cardiac surgery with or without LAAO. Six studies met our inclusion criteria with a total of 4130 patients: 2146 in the LAAO group and 1984 in the no-LAAO group. The risk ratio of postoperative AF was 1.05 (95% CI, 0.86-1.28); P=0.628. The CVA rates at 5 years were 6.8±1.0% in the no-LAAO group and 4.3±0.8% in the LAAO group (log-rank P=0.021). The Cox regression analysis for CVA in patients undergoing LAAO reported a hazard ratio of 0.65 (95% CI, 0.45-0.94); P=0.022. Landmark analysis at 4 years highlighted a significant difference in overall survival between no-LAAO and LAAO groups, 86±12.2% versus 89.6±11.0%; P=0.041. In this meta-analysis of patients without previous AF undergoing cardiac surgery, LAAO was associated with a decreased risk of CVA, no difference in the incidence of postoperative atrial fibrillation, and a significant overall survival benefit at a 4-year landmark analysis. Although these findings support LAAO, the randomized LeAAPS trial (Left Atrial Appendage Exclusion for Prophylactic Stroke Reduction Trial), LAA-CLOSURE trial (A Randomized Prospective Multicenter Trial for Stroke Prevention by Prophylactic Surgical Closure of the Left Atrial Appendage in Patients Undergoing Bioprosthetic Aortic Valve Surgery), and LAACS-2 trial (Left Atrial Appendage Closure by Surgery-2) will help define the effectiveness of LAAO in patients undergoing cardiac surgery who have risk factors for AF and CVA. URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42024496366.

Abstract Mo039: Risk of Structural and Hemodynamic changes in Left Atrium in Patients with Heart Failure undergoing Percutaneous Left Atrial Appendage Occlusion: A Retrospective Analysis

Background: Exclusion of left atrial appendage (LAA) in animals reduces compliance and increases left atrial pressure. We hypothesize that percutaneous left atrial appendage occlusion (LAAO) would lead to structural and hemodynamic changes in left atrium and assess the risk using echocardiographic cut-offs used for evaluating left atrial pressure in heart failure patients. Methods: We queried TriNetx database for adult patients with heart failure undergoing percutaneous LAAO. We excluded those who underwent surgical or alternative percutaneous procedures pertaining to LAA, procedures pertaining to mitral valve (MV), mitral valvular pathologies, mechanical circulatory support placement, pacemaker placement, and those with left bundle branch block. We calculated risk of meeting echocardiographic cut-offs used in evaluation of left atrial pressure; MV maximum E-wave velocity ≥50cm/s, left atrial end systolic volume index (LAESVI) indexed to body surface area ≥34 ml/m2, Tricuspid Regurgitation systolic jet velocity ≥ 2.8 m/s, Pulmonary vein Systole/Diastole ratio ≤ 1, mitral valve lateral annulus E/e' ≥ 13 and Mitral valve E/A ratio ≥2. Those meeting the respective cut-off before LAAO were excluded. All diagnoses, procedures, and echocardiographic parameters were identified using International Classification of Diseases, Current Procedural Terminology, and Logical Observation Identifiers Names and Codes. Results: We identified 4,046 patients with heart failure undergoing percutaneous LAAO. Baseline demographics and diagnosis were; mean (SD) age 75.4 (8.1) years, 37% females, 92% hypertension, 67% ischemic heart disease, 42% diabetes mellitus, 41% chronic kidney disease, and 42% were overweight or obese. Risk of meeting echocardiographic cut-offs used in evaluating left atrial pressure was low with 0.24% (10) patients having LAESVI indexed to body surface area ≥34 ml/m2, Tricuspid Regurgitation systolic jet velocity ≥ 2.8 m/s, Pulmonary vein Systole/Diastole ratio ≤ 1, and Mitral valve E/A ratio ≥ 2. Risk of having MV maximum E-wave velocity ≥50cm/s was 0.58% and no patients had mitral valve lateral annulus E/e' ≥ 13. (Figure 1) Conclusion: Risk of meeting echocardiographic cut-offs used in evaluation of left atrial pressure in patients with heart failure undergoing percutaneous LAAO is low.

Understanding the role of the left atrial appendage on the flow in the atrium.

The exclusion/occlusion of the left atrial appendage (LAA) is a treatment option for atrial fibrillation (AF) patients who are at high risk of stroke and high risk of bleeding. As the role of the LAA is not well understood or explored, this study aims to assess its role on flow dynamics in the left atrium. Computational fluid dynamics (CFD) simulations were carried out for nine AF patients before and after LAA exclusion. The flow parameters investigated included the LA velocities, Time Averaged Wall Shear Stress (TAWSS), Oscillatory Shear Index (OSI), Relative Residence Time (RRT), and Pressure in the LA. This study shows that, on average, a decrease in TAWSS (1.82 ± 1.85 Pa to 1.27 ± 0.96 Pa, p < 0.05) and a slight increase in OSI (0.16 ± 0.10 to 0.17 ± 0.10, p < 0.05), RRT (1.87 ± 1.84 Pa-1 to 2.11 ± 1.78 Pa-1, p < 0.05), and pressure (-19.2 ± 6.8 mmHg to -15.3 ± 8.3 mmHg, p < 0.05) were observed in the LA after the exclusion of the LAA, with a decrease in low-magnitude velocities. The exclusion of the LAA seems to be associated with changes in LA flow dynamics. Further studies are needed to elucidate the clinical implications of these changes.

Two-year safety and effectiveness of hybrid ablation versus catheter ablation in patients with non-paroxysmal AF: mid-term results of the CEASE-AF trial

Abstract Background Hybrid Ablation for atrial fibrillation (AF) combines epicardial and endocardial ablation through a Heart Team approach to target durable, transmural isolation of the pulmonary veins (PV) and left atrial posterior wall (LAPW). While the primary efficacy endpoint at 12 months was met with a significant benefit increase for hybrid ablation, we now report the midterm durability of those results. Purpose To evaluate 24-months safety and effectiveness of Hybrid Ablation with left atrial appendage exclusion (LAAE) versus Catheter Ablation in patients with persistent AF/enlarged left atrium and longstanding persistent AF (LSPAF). Methods CEASE-AF is a prospective, multi-center, 2:1 randomized controlled trial. Eligible patients were 18-75 years of age, had symptomatic, drug-refractory persistent AF and enlarged left atrium (&amp;gt;4 cm) or LSPAF, and were undergoing a first ablation. Hybrid Ablation consisted of two stages: thoracoscopic epicardial radiofrequency (RF) ablation for PV and LAPW isolation and epicardial LAAE followed by endocardial ablation 91-180 days later. Catheter Ablation consisted of minimum PV isolation by endocardial RF ablation, and repeat ablation was allowed between 91-180 days. In both arms, additional lesions were permitted according to institutional practices. Effectiveness was freedom from AF/atrial flutter (AFL)/atrial tachycardia (AT) off anti-arrhythmic drugs (AAD) (except AADs not exceeding doses which previously failed) and was assessed through 48-h Holter monitoring reviewed by an independent core laboratory blinded to the study. Safety was major adverse events throughout the study, adjudicated by an independent Clinical Events Committee. Results There were 102 Hybrid Ablation and 52 Catheter Ablation patients; 26% were female, mean age was 60.7±7.9 years, mean LAD was 4.7±0.4 cm, and 19% had LSPAF with no differences between arms. The 12- and 24-month results are shown for comparison (Table). Through 24-months, effectiveness was 66.3% (63/95) in the Hybrid Arm and 33.3% (17/51) in the Catheter Arm (absolute difference 33.0% [95% CI 14.3%, 48.3%; p&amp;lt;0.001]). Major adverse event rates through 24-months were statistically similar at 10.8% (11/102) in the Hybrid Arm and 9.6% (5/52) in the Catheter Arm (p=1.0). Through 24-months, repeat ablations were performed in 7.4% (7/95) of the Hybrid Arm versus 37.3% (19/51) of the Catheter Arm (p&amp;lt;0.001), and cardioversions were performed in 14.7% (14/95) of the Hybrid Arm versus 29.4% (15/51) of the Catheter Arm (p=0.034) Conclusions: CEASE-AF demonstrated that superior effectiveness of Hybrid Ablation including LAAE versus Catheter Ablation was durable through 24-month follow-up, with 33% absolute improvement in freedom from AF/AFL/AT. Safety rates continued to be similar between arms. Three-year follow-up is ongoing.

Left atrial appendage clipping during hybrid atrial fibrillation ablation: a very long-term, single-center experience

Abstract Background/introduction Epicardial left atrial appendage (LAA) clipping is an effective strategy for stroke prophylaxis in high thromboembolic (TE) and bleeding risk patients with atrial fibrillation (AF). In addition to LAA exclusion from systemic circulation, clipping promotes concomitant appendage isolation, which might have positive impacts on arrhythmia control. Purpose The aim of this study was to report safety, success rate, and the long-term clinical outcomes of LAA clipping in a large cohort of AF patients undergoing concomitant hybrid ablation. Methods Consecutive patients undergoing hybrid AF ablation between 2013 and 2023 were enrolled. Hybrid ablation was performed in a one-step procedure consisting of thoracoscopic epicardial radiofrequency (RF) ablation followed by endocardial mapping and ablation, if needed. Ablation lesion set included pulmonary vein (PV) and posterior wall (PW) isolation, as well as RF applications to the LAA/posterolateral ridge. LAA clipping was performed via Atriclip exclusion system (Atricure, Inc., The Nederlands) after epicardial ablation. Additional endocardial lesions were performed in case of incomplete epicardial ablation or at physician’s discretion. Results A total of 130 patients were included (mean age: 65±9.4; 72.3% males); among them, 19.2% and 55.4% had persistent or long-standing persistent AF, respectively. Mean CHA2DS2-VASC and HAS-BLED were 3.1±1.1 and 2.3+-0.5. Five patients (3.8 %) had absolute contraindication to long-term oral anticoagulation, 3 (2.3%) had previous life-threatening bleeding events, 17 (13.1%) had a previous TE event. The final clip size was 35mm in 90.7% cases. Acute success was achieved in 97.7%; failure was due to LAA size (n=1), proximity to phrenic nerve (n=1), or bypass graft (n=1). One patient had incomplete occlusion due to a large secondary lobe, which required a second clip. No periprocedural complications related to clipping were documented. At a mean follow-up of 51±35 months, one (0.8%) patient had a stroke and 3 (2.3%) a transient ischemic attack (4 events per 552 patient/years; 0.7%). One patient had a microreentrant tachycardia mapped from the area near the LAA clipping. Conclusion In a large cohort undergoing hybrid AF ablation, epicardial LAA clipping was safe and highly successful. Acute failure was rare and due to LAA morphology or proximity to phrenic nerve and bypass graft. Thromboembolic event rate was very low.

C-49 | Concomitant Left Atrial Appendage Exclusion during Cardiac Surgery for patients without a diagnosis of Atrial Fibrillation: A NATIONWIDE ANALYSIS

C-49 | Concomitant Left Atrial Appendage Exclusion during Cardiac Surgery for patients without a diagnosis of Atrial Fibrillation: A NATIONWIDE ANALYSIS

Noncomplex ventricular arrhythmia associated with greater freedom from recurrent ectopy at 1 year after mitral repair surgery

ObjectiveThe effect of mitral valve (MV) surgery on the natural history of ventricular arrhythmia (VA) in patients with arrhythmic MV prolapse remains unknown. We sought to evaluate the cumulative incidence of VA at 1 year after surgical mitral repair. MethodsA retrospective review of progressively captured data identified 204 consecutive patients who underwent elective MV repair for significant degenerative mitral regurgitation as a first-time cardiovascular intervention in a quaternary reference center between January 2018 and December 2020. A subset of 62 consecutive patients with diagnosed arrhythmic MV prolapse was further evaluated for recurrent VA after MV repair. ResultsThe median age was 62 years (range, 27-77 years) and 26 of 62 (41.9%) were female. The median time from initial mitral regurgitation/MV prolaspe diagnosis-to-referral was 13.8 years (interquartile range [IQR], 5.4-25) and from VA diagnosis-to-referral was 8 years (IQR, 3-10.6). Using the Lown-Wolf classification, complex VA (Lown grade ≥3) was identified in 36 of 62 patients (58%) at baseline, whereas 8 of 62 (13%) had a cardioverter/defibrillator implanted for primary (4/8) or secondary (4/8) prevention. Left ventricular myocardial scar was confirmed in 23 of 34 (68%) of patients scanned at baseline. The prevailing valve phenotype was bileaflet Barlow (59/62; 95.2%). All patients underwent surgical MV repair by the same team. Surgical repair was stabilized with an annuloplasty prosthesis (median size 36 mm [IQR, 34-38]). Concomitant procedures included tricuspid valve repair (51/62; 82.3%), cryo-maze ± left atrial appendage exclusion (14/62, 23%), and endocardial cryoablation of VA ectopy (4/62; 6.5%). The 30-day and 1-year freedom from recurrent VA were 98.4% and 75.9%, respectively. Absent VA after mitral repair was uniformly observed in patients with minor VA at baseline. Absent VA after mitral repair was uniformly observed in patients with minor VA preoperatively. Complex baseline VA was the strongest predictor of recurrent VA (hazard ratio, 10.8; 95% confidence interval, 1.4-84.2; P = .024), irrespective of myocardial fibrosis. ConclusionsIn a series of 62 consecutive patients operated electively for arrhythmic mitral prolapse, VA remained undetected in 75.9% of patients at 1 year. Freedom from recurrent VA was greater among patients without complex VA preoperatively, whereas baseline Lown grade ≥3 was the strongest independent risk factor for recurrent VA at 1 year. These findings attest to the importance of early recognition and prompt referral of patients with mitral prolapse and progressive VA to specialty interdisciplinary care.

Four-year follow-up of outcomes of the hybrid epicardial-endocardial ablation: A single-center experience

BackgroundThe CONVERGE trial demonstrated that hybrid epicardial and endocardial ablation was more effective than catheter ablation for the treatment of persistent atrial fibrillation (AF) at 1 year. Long-term real-world outcome data are scarce. ObjectiveWe described a single-center experience by evaluating the long-term effectiveness and safety of hybrid epicardial-endocardial ablation. MethodsThis is a retrospective single-center study. Patients were followed up to 4 years. The primary end point was the rate of AF recurrence up to 4 years postablation. Secondary end points included reduction in antiarrhythmic therapy use, the effect of the ligament of Marshall removal, epicardial posterior wall, 3-dimensional mapping during epicardial ablation, and left atrial appendage exclusion as adjunct intraoperative interventions for AF recurrence. ResultsOf the 170 patients, 86.5% had persistent AF and 13.5% had long-standing persistent AF. AF-free survival was 87.6% at 1 year, 76.9% at 2 years, 70.4% at 3 years, and 59.3% at 4 years. Antiarrhythmic drug use was 87.6% at baseline and reduced to 21%, 20.6%, 18%, and 14.1% at year 1, 2, 3, and 4, respectively (P < .01 for all). Three-dimensional epicardial mapping showed a significant reduction in combined recurrence from 42% to 25% over 4 years of follow-up (P = .023). Ligament of Marshall and left atrial appendage exclusion showed numerical reduction in AF recurrence from 35% to 26% (P = .49) and from 44% to 30% (P = .07). ConclusionThe hybrid convergent procedure reduces AF recurrence and the need for antiarrhythmic drugs and, while maintaining a good safety profile, for the treatment of persistent and long-standing persistent AF.

Clinical outcomes of patients referred for left atrial appendage exclusion who did and did not undergo the procedure

BackgroundLeft atrial appendage exclusion (LAAE) is an effective alternative to long-term anticoagulation in patients with atrial fibrillation. Not all patients considered for LAAE undergo the procedure because of ineligibility, anatomic or medical constraints, and preference of the patient. ObjectiveThe objective of this study was to report on the management strategies and long-term clinical outcomes of patients referred to a dedicated multidisciplinary LAAE clinic, including all who subsequently did and did not undergo LAAE. MethodsThis was a retrospective analysis of prospectively acquired data from all patients referred to the comprehensive multidisciplinary LAAE clinic at the University of Michigan between 2016 and 2022. A consecutive 301 patients (age, 75 ± 8 years; 106 women) with atrial fibrillation were evaluated. LAAE was performed in 168 patients (56%) with use of the Watchman device in 146 (49%) and surgically in 22 (7%). LAAE was not performed in 133 patients (44%, no-LAAE group) because of ineligibility in 62 (21%), anatomic constraints in 23 (7%), and preference of the patient in 48 (36%). The CHA2DS2-VASc score (4.7 ± 1.5 vs 4.1 ± 1.6; P = .002) and HAS-BLED score (3.4 ± 1.0 vs 2.8 ± 1.1; P < .001) were higher in the LAAE groups. ResultsAnticoagulant therapy was discontinued in 137 of 146 (94%) and 61 of 133 (61%) in the Watchman and no-LAAE groups, respectively (P < .001). During a median follow-up of 2.2 years (interquartile range, 1.2–4.0 years), in the LAAE (n = 168) and no-LAAE (n = 133) groups, respectively, 39 (23%) vs 29 (22%) deaths, 13 (8%) vs 5 (4%) thromboembolic events, and 24 (14%) vs 23 (17%) bleeding complications occurred. Continued long-term anticoagulation was not a predictor of clinical outcomes. ConclusionAfter a comprehensive evaluation in a multidisciplinary clinic, ∼50% of the patients referred for LAAE did not proceed with LAAE and resumed anticoagulation.

Minimally invasive epicardial surgical left atrial appendage exclusion for atrial fibrillation patients at high risk for stroke and for bleeding

BackgroundAtrial fibrillation (AF) patients at high risk for stroke and for bleeding may be unsuitable for either oral anticoagulation or endocardial left atrial appendage (LAA) occlusion. However, minimally invasive, epicardial left atrial appendage exclusion (LAAE) may be an option. ObjectiveThe purpose of this study was to evaluate outcomes of LAAE in high-risk AF patients not receiving oral anticoagulation. MethodsA retrospective analysis of Medicare claims data was conducted to evaluate thromboembolic events in AF patients who underwent LAAE compared to a 1:4 propensity score–matched group of patients who did not receive LAAE (control). Neither group was receiving any oral anticoagulation at baseline or follow-up. Fine-Gray models estimated hazard ratios and evaluated between-group differences. Bootstrapping was applied to generate 95% confidence intervals (CIs). ResultsThe LAAE group (n = 243) was 61% male (mean age 75 years). AF was nonparoxysmal in 70% (mean CHA2DS2-VASc score 5.4; mean HAS-BLED score 4.2). The matched control group (n = 972) had statistically similar characteristics. One-year adjusted estimates of thromboembolic events were 7.3% (95% CI 4.3%–11.1%) in the LAAE group and 12.1% (95% CI 9.5%–14.8%) in the control group. Absolute risk reduction was 4.8% (95% CI 0.6%–8.9%; P = .028). Adjusted hazard ratio for thromboembolic events for LAAE vs non-LAAE was 0.672 (95% CI 0.394–1.146). ConclusionIn AF patients not taking oral anticoagulation who are at high risk for stroke and for bleeding, minimally invasive, thoracoscopic, epicardial LAAE was associated with a lower rate of thromboembolic events.

Definition and anatomical description of the left atrial appendage neck.

The left atrial appendage (LAA) is well known as a source of cardiac thrombus formation. Despite its clinical importance, the LAA neck is still anatomically poorly defined. Therefore, this study aimed to define the LAA neck and determine its morphometric characteristics. We performed three-dimensional reconstructions of the heart chambers based on contrast-enhanced electrocardiography-gated computed tomography scans of 200 patients (47% females, 66.5 ± 13.6 years old). The LAA neck was defined as a truncated cone-shaped canal bounded proximally by the LAA orifice and distally by the lobe origin and was present in 98.0% of cases. The central axis of the LAA neck was 14.7 ± 2.3 mm. The mean area of the LAA neck walls was 856.6 ± 316.7 mm2 . The LAA neck can be divided into aortic, arterial (the smallest), venous (the largest), and free surfaces. All areas have a trapezoidal shape with a broader proximal base. There were no statistically significant differences in the morphometric characteristics of the LAA neck between LAA types. Statistically significant differences between the sexes in the main morphometric parameters of the LAA neck were found in the central axis length and the LAA neck wall area. The LAA neck can be evaluated from computed tomography scans and their three-dimensional reconstructions. The current study provides a complex morphometric analysis of the LAA neck. The precise definition and morphometric details of the LAA neck presented in this study may influence the effectiveness and safety of LAA exclusion procedures.

Abstract 15606: Effectiveness and Safety of the Dual Epicardial &amp; Endocardial Procedure (DEEP) Approach for Treatment of Subjects With Persistent or Long Standing Persistent Atrial Fibrillation (PersAF/LSPAF) With Radiofrequency Ablation

Background: A collaborative approach between Electrophysiologists (EP) and Cardiothoracic Surgeons (CTS) to effectively target pulmonary veins (PVs) and substrate beyond PVs may improve outcomes for persistent and longstanding persistent AF (PersAF/LSPerAF). Hypothesis: A minimally invasive hybrid approach of bilateral thoracoscopic epicardial ablation and left atrial appendage exclusion (LAAE) with endocardial mapping/ablation (Hybrid approach) is safe and effective to treat advanced AF patients who have failed medical therapy. Aim: DEEP (NCT02393885) aims to establish safety and effectiveness of a Bipolar Radiofrequency (RF) System in a Hybrid approach to treat PersAF/LSPerAF. Methods: DEEP is a prospective, international, single arm trial at 17 sites. Key eligibility: adults with drug refractory PersAF/LSPerAF, left atrial diameter (LAD) ≤5.5cm, failed class I/III AAD, and ≤2 previous failed endocardial catheter ablations (CA). Epicardial surgical ablation included PV isolation, roof and floor lines (posterior LA box), left superior PV to LAA lesion, ganglionic plexi and Ligament of Marshall ablation and LAAE. CA followed 91-121 D post epicardial procedure. After 90 D blanking and 90 D AAD optimization periods, 24-hr rhythm monitoring and ECG were performed 6 and 12 M post CA with symptom driven monitoring between. Primary effectiveness was defined as freedom from atrial arrhythmia (&gt;30 sec) absent new/increased dose of previously failed AAD through 12 M. Safety was device/procedure-related SAEs within 30 D of epicardial ablation and 7 D of CA in all who received anesthesia. Results: Ninety patients were enrolled in 2015-2020, 83.3% PersAF, 16.7% LSPerAF, mean age 63.4±7.74 yrs, 83.3% male, mean BMI 29.9, CHAD2DS2-VASc median 2.0 (1.0, 3.0), 48% failed CA, median AF duration 3.8 yrs, mean LAD 4.5cm. Primary effectiveness 70.6% (60/85; 95% CI 60.9%, 80.3%, p=0.0232) and freedom from AF through 12 M 78.8% (p=0.0002). The adverse event rate was 6.7% (6/90); equal in epi- and endocardial cohort. Both primary endpoints met prespecified success criteria. Conclusion: A collaborative approach between EP and CTS to Hybrid ablation is effective for PersAF/LSerPAF when benefit-risk is deemed favorable, given limited alternative treatments.

Video-assisted thoracoscopic epicardial pacing: A contemporary overview.

Video-assisted thoracoscopic surgery (VATS) has revolutionized the approach and management of pulmonary and cardiac diseases, and its applications have significantly expanded in the last two decades. Beyond its established role in thoracic procedures, VATS has also emerged as a valuable technique for various electrophysiological procedures, including pacemaker implantations, ablation procedures, and left atrial appendage exclusion. This paper presents a thorough review of the existing literature on pacing procedures performed using a VATS approach. By analyzing and synthesizing the available studies, we aim to provide an in-depth understanding of the current knowledge and advancements in VATS-based pacing procedures. A key focus of this review is the detailed description of implantation techniques via a VATS approach.