Thoracoscopic Left Atrial Appendage Research Articles

Thoracoscopic Left Atrial Appendage Occlusion with the AtriClip PRO2: An Experience of 144 Patients

To report the clinical outcomes of thoracoscopic left atrial appendage occlusion (LAAO) with the AtriClip PRO2 device (Atricure Inc, Mason, OH, USA). Stroke risk reduction with LAAO in patients with atrial fibrillation is now well-established. Many surgical and percutaneous techniques have been used, with varying rates of success. The percutaneous devices have had issues with procedural complications and peridevice flow. Thoracoscopic AtriClip offers an epicardial linear closure of the appendage at its ostium. This study sought to evaluate its safety and efficacy in achieving complete LAA closure. This is a prospective series of thoracoscopic AtriClip PRO2 as a standalone procedure or a thoracoscopic AtriClip deployed as an adjunct to minimal access cardiac and thoracic surgery. Study ethical approval was granted by the hospital Human Research Ethics Committee. In total, 144 thoracoscopic AtriClip procedures were conducted by a single surgeon from 2017 to 2022, 56 standalone and 88 concomitant. There was no mortality or major morbidities. A 100% success in complete LAA closure was observed, with 87% complete follow-up imaging. For patients that underwent standalone AtriClip after cessation of anticoagulation, no thromboembolic phenomena were seen in the 180 patient-years of follow-up. This study demonstrates that thoracoscopic placement of AtriClip is safe and effective in achieving consistent and complete LAAO. Future randomised trials will be useful to compare outcomes with percutaneous devices.

THORACOSCOPIC LEFT ATRIAL APPENDAGE AMPUTATION CAN BE AN ALTERNATIVE TO ENDOVASCULAR OCCLUSION

HighlightsWe present a clinical case of a patient with atrial fibrillation and a high bleeding risk according to HAS-BLED bleeding risk score who underwent thoracoscopic left atrial appendage (LAA) occluder implantation due to lack of endovascular access. Thoracoscopic amputation of LAA also can be performed in cases where an endovascular access cannot be achieved due to occlusion of the inferior vena cava or thrombosis of LAA. However, it is necessary to monitor the condition of the stump when conducting thoracoscopic amputation of LAA, and stop anticoagulation therapy only in case of non-embologenic stump. AbstractAtrial fibrillation is the most common rhythm disorder that can be conservatively treated using antiarrhythmic therapy, and anticoagulants can be used to prevent thromboembolic complications. However, prolonged use of anticoagulants is complicated by the risk of bleeding. Left atrial appendage (LAA) occluder implantation is an alternative way of preventing of thromboembolic and hemorrhagic complications. The article presents a clinical case of thoracoscopic LAA amputation after unsuccessful endovascular LAA occluder implantation in the patient with the inferior vena cava occlusion.

Epicardial left atrial appendage clipping versus direct oral anticoagulant to reduce stroke risk in non-paroxysmal atrial fibrillation (LAA-CLIP): rationale, design and study protocol for a multicentre randomised controlled trial

IntroductionThe prevalence of atrial fibrillation (AF) is increasing globally, and stroke prevention is the key to reduce the morbidity and mortality related to AF. Currently, direct oral anticoagulants (DOACs) are...

A Comparative Study of Thoracoscopic Left Atrial Appendage Clipping vs Stapled Resection

BackgroundThe left atrial appendage (LAA) is the predominant site of thrombus formation in atrial fibrillation (AF), which is associated with ischemic stroke. This study comparatively evaluated the complete LAA closure rates between LAA clipping and stapled resections. MethodsThe study included 333 patients who underwent thoracoscopic operation with both preoperative and postoperative computed tomographic scans. Propensity score matching (4:1 ratio) was applied, matching 90 LAA clipping patients with 206 stapled resection patients. The primary end point was complete LAA closure, defined as a residual LAA depth of <1 cm on computed tomographic images obtained 1 year postoperatively. ResultsNo 30-day death was observed. Complete LAA closure was achieved in 85.9% (286 of 333) of patients. After propensity score matching, the clipping group demonstrated a significantly higher complete LAA closure rate than the stapled resection group (95.6% vs 83.0%, P = .003). The residual LAA stump depth was also shorter in the clipping group compared with the stapled resection group (2.9 vs 5.3 mm, P = .001). Two patients with a residual LAA stump exhibited an association with ischemic stroke during follow-up. ConclusionsThe clipping group demonstrated a higher rate of complete LAA closure compared with the stapled resection group. Close monitoring of patients with residual LAA stumps is essential. Further research with larger cohorts is needed to elucidate impact of the residual LAA stump on thromboembolic events.

Left atrial function after thoracoscopic left atrial appendage exclusion as standalone and as combined with epicardial atrial fibrillation ablation: echocardiographic findings at one- year follow up

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left atrial appendage (LAA) is the most common source of thrombi in patients with atrial fibrillation (AF). The Totally Thoracoscopic (TT)-LAA exclusion with epicardial clip is an effective procedure, however the effects on left atrial (LA) function remain unknown. Purpose The aim of this study was to assess the impact of TT-LAA exclusion on the LA function in patients undergoing to standalone TT-LAA exclusion and patients received combined procedure, namely: TT-LAA exclusion and Thoracoscopic Epicardial Ablation (TEA). Methods 39 AF Patients underwent to TT-LAA exclusion with the clip. Indication to standalone TT-LAA exclusion was: high risk for ischemic stroke or contraindication to long-term anticoagulant therapy. All patients were screened preoperatively with 3D CT scan, transthoracic and trans-esophageal echocardiography. Intraoperative clip positioning and LAA exclusion were guided by trans-esophageal echo. To evaluate LA function, standard transthoracic echocardiography and 2D strain of LA were performed before surgery, at discharge (3-4 days after the procedure), at 3-month and at 1 year. Routine blood tests and BNP levels were also measured. Results The study enrolled 39 consecutive patients, 25 underwent to standalone TT-LAA exclusion (mean age 78.6 ± 5.7 years, 79% males), and 14 LAA exclusion during TEA (mean age 64.5 ± 8.2 years, 82% males). The mean CHA2DS2-VASc and HASBLED scores were 3.5 and 2.1 respectively. Baseline characteristics are summarized in Figure 1. There were no major complications during the procedure. At median follow-up of 13 months, 1 non cardiovascular death, 1 ischemic stroke and 4 cardiovascular hospitalizations occurred. At 2D strain of LA, the reservoir function decreased significantly after clip implantation and recovered at 3-months follow-up; at 1 year it remained stable. Furthermore, NT-proBNP increased significantly after LAA exclusion with a return to baseline after 3 months. Changes in E/A occurred at predischarge and did not persist at follow up. Echocardiographic findings are summarized in Figure 2. Patients with indication to TEA and LAA exclusion presented a lower LA volume and a lower strain value. Conclusion The main findings of this study can be summarized as follows: 1) The amputation of LAA is a safe procedure at long term follow up. 2) LAA amputation with the clip is associated with acute elevation of BNP levels the days after the procedure with return to baseline at 3 months and one year. 3) LAA amputation impairs the LA reservoir function after the procedure, with recovery after 3 months and remains preserved at one-year. This occurs either when LA strain is measured in sinus rhythm or in AF. 4) LAA exclusion results in a change in E/A that does not persist at three months follow-up and at 1 year. 5) Patients with indication to epicardial AF ablation and LAA exclusion present a lower LA volume with a lower strain value than patients undergoing standalone TT-LAA exclusion.

The role of cardiac imaging before and after left atrial appendage standalone thoracoscopic exclusion.

To assess the characteristics of left atrial appendage (LAA) stump and left atrial (LA) volume after standalone totally thoracoscopic LAA exclusion in 40 patients with nonvalvular atrial fibrillation (NVAF) and contraindications to oral anticoagulation (OAC), using cardiac computed tomography (CCT) and transoesophageal echocardiography (TOE). Using CCT and TOE, we evaluated correct AtriClip Pro II positioning, the presence and characteristics of the LAA stump and the postprocedural LA volume, at 3 months' follow-up. Stump depth was measured with both CCT and TOE using a new method, based on left circumflex artery (LCX) course. After placement of AtriClip, all 40 patients discontinued OAC, and no stroke occurred. LAA exclusion was achieved in 40/40 patients at 3 months' follow-up. LAA stump (depth <10 mm in 12/18 stump, 67%) was observed in 18 patients. The overall (LA + LAA) volume and isolated LA volume were statistically different when comparing cases with and without LAA stump (P < 0.02). LAA ostium dimensions (perimeter and area) and LAA volume correlate with stump depth (P < 0.02). There was a high correlation between CCT and TOE in stump identification and depth measurement (P < 0.02). Compared with the baseline, CCT LA volume increased (P < 0.01) at 3 months' follow-up. Preprocedural and postprocedural CCT and TOE are useful and comparable in patients undergoing standalone totally thoracoscopic exclusion of LAA, because these imaging methods can identify anatomical LAA and LA characteristics predisposing for a postprocedural residual stump.

Thoracoscopic Left Atrial Appendage Exclusion for Atrial Fibrillation Patients Intolerant to Anticoagulation.

Outcomes associated with isolated epicardial left atrial appendage (LAA) exclusion in atrial fibrillation (AF) patients with a contraindication or intolerance to anticoagulation are not clearly defined, especially in patients with prior stroke. This study evaluated the perioperative safety, medication use, and stroke outcomes for isolated thoracoscopic LAA exclusion for stroke prevention. A single-center retrospective study was performed of adults undergoing isolated thoracoscopic LAA exclusion with an epicardial exclusion device without a concomitant surgical procedure. Descriptive statistics were performed. Twenty-five patients met the inclusion criteria. The cohort was 68% male (n = 17) with a mean age of 76.4 ± 6.5 years, a mean preoperative CHA2DS2-VASc score of 4.2 ± 1.4, and a mean preoperative HAS-BLED score of 2.68 ± 1.03. Seventeen patients (68%) had nonparoxysmal AF. There were 11 patients with intolerance of anticoagulation due to intracranial hemorrhage (44%), 6 due to gastrointestinal bleeding (24%), and 4 due to genitourinary bleeding (16%). All procedures were performed thoracoscopically with 100% technical success-the mean LAA stump length was 5.5 ± 2.3 mm on intraoperative transesophageal echocardiography. The median hospital length of stay was 2 (interquartile range [IQR] 1, 6.5) days. The median follow-up time was 430 (IQR 125, 972) days. During follow-up, 1 patient with cerebral angiopathy had temporary neurologic deficits at an outside institution, with brain imaging showing no evidence of ischemic injury. There were no other thromboembolic events over the 38.8 postoperative patient-years examined. All patients were off anticoagulation at last follow-up. This study shows the perioperative safety, technical success, freedom from anticoagulation, and stroke outcomes of isolated thoracoscopic LAA exclusion in patients with AF at high risk for thromboembolic disease.

Early myocardial injury and coagulation activation in thoracoscopic left atrial appendage clipping.

Thoracoscopic left atrial appendage clipping as a new strategy for stroke prevention. This study was established to observe the changes in myocardial injury and coagulation during the perioperative to provide the basis for anticoagulation strategy. Fifty-two patients with nonvalvular atrial fibrillation who completed thoracoscopic left atrial appendage clipping alone and 52 matched controls with thoracoscopic lobectomy were included in the study. The changes in coagulation and myocardial enzyme during the perioperative period were compared by t-test or nonparametric test. Linear correlation analysis was performed on the trend changes of each indicator in the left atrial appendage clipping group. Compared with the control group, the postoperative cardiac troponin I level in the thoracoscopic left atrial appendage clip group was significantly higher than that before the operation; there was no significant difference in the increase of myoglobin between the two groups. In the coagulation function, there was no significant difference in the increase of fibrinogen between the two groups. Postoperative D-dimer and fibrin degradation products were significantly increased, especially the left atrial appendage clip group was significantly higher than the control group, and even showed a trend of secondary increase. Cardiac troponin I was positively correlated with C-reactive protein, fibrinogen and von Willebrand Factor activity, and the Spearman nonparametric correlation coefficients were 1, 0.829, and 0.829, respectively (all p < .05). Thoracoscopic left atrial appendage closure surgery presents early myocardial injury and activation of coagulation function. The secondary increase of coagulation index needs our attention.

Left atrial function after standalone totally thoracoscopic left atrial appendage exclusion in atrial fibrillation patients with absolute contraindication to oral anticoagulation therapy.

Left atrial appendage (LAA) is a common source of thrombi in patients with atrial fibrillation (AF). The effect on left atrial (LA) function of the Totally Thoracoscopic (TT)-LAA exclusion with epicardial clip is currently unknown. This study aims at evaluating the effect of TT-LAA exclusion on LA function. Standalone TT-LAA exclusion with the clip device was performed in 26 patients with AF and contraindication to oral anticoagulation (OAC). A 3D CT scan, trans-esophageal echocardiography, spirometry and cerebrovascular doppler ultrasound were performed preoperatively. Clip positioning and LAA exclusion were guided and confirmed by intraoperative trans-esophageal echo. To evaluate LA function, standard transthoracic echocardiography and 2D strain of LA were performed before surgery, at discharge and at 3-month follow-up. The mean CHA2DS2-VASc and HASBLED scores were 4.6 and 2.4 respectively. There were no major complications during the procedure. At median follow-up of 10.3 months, 1 (3.8%) non-cardiovascular death, 1 (3.8%) stroke and 4 (15.4%) cardiovascular hospitalizations occurred. At 2D strain of LA, the reservoir function decreased significantly at discharge, compared to baseline and recovered at 3-months follow-up. Furthermore, NT-proBNP increased significantly after the procedure with a return to baseline after 3 months. Changes in E/A were persistent at 3 months. Our data in a small cohort suggest that TT-LAA exclusion with epicardial clip can be a safe procedure with regards to the atrial function. The LAA amputation impairs the reservoir LA function on the short term, that recovers over time.

The Significant Decrease of Serum Sodium and Blood Pressure following Thoracoscopic Left Atrial Appendage Clipping

Background: The epicardial left atrial appendage (LAA) closure may induce unwanted natriuretic peptides caused by the isolation of the LAA from circulation. Thus, this study aims to explore the possible change of blood pressure and electrolytes following the procedure. Methods: This was a retrospective, observational study including 52 atrial fibrillation (AF) patients with a history of thrombolic stroke who underwent thoracoscopic LAA clipping. Electrolytes, blood pressure, and brain natriuretic peptide were measured before the procedure, immediately after the device release, on the 1st day, the 2nd day postoperation, and discharge. Results: Thirty-five (66.04%) patients’ serum sodium level decreased by more than 4 mmol/L during 48 h postoperation. The systolic blood pressure at discharge was significantly lower than the baseline level (118.99 ± 12.29 mmHg vs. 122.93 ± 13.82 mmHg, p = 0.034), while the diastolic blood pressure was not significantly different to the baseline (78.00 ± 7.39 mmHg vs. 77.22 ± 7.72 mmHg, p = 0.502). A significant increase in brain natriuretic peptide was observed postoperatively, although it showed a trend of decline at discharge. Conclusion: Epicardial LAA clipping could induce an acute decrease in serum sodium postoperation, which indicates to the surgeons that the postoperative intake fluid amounts and serum sodium level management should be more appropriate. The decrease in systolic blood pressure indicates the possibility of expanding the benefits that patients received from LAA clipping, though further studies are needed to determine if this phenomenon is persistent in the long-term follow-up.

Stroke prevention of thoracoscopic left atrial appendage clipping in patients with non-valvular atrial fibrillation at high risk of stroke and bleeding: study protocol for a non-randomised controlled clinical trial

IntroductionNon-valvular atrial fibrillation (NVAF) is a high-risk factor for ischaemic stroke. The 2016 European Society of Cardiology Atrial Fibrillation Management guidelines recommend oral anticoagulants (OACs) to prevent stroke in men...

Immersive 3D Virtual Reality-Based Clip Sizing for Thoracoscopic Left Atrial Appendage Closure.

Objective: Surgical left atrial appendage (LAA) closure using epicardial clips has become popular in stroke prevention in patients with atrial fibrillation. Optimal placement of the clip is essential to achieve complete LAA occlusion and to prevent complications due to compression of the circumflex artery. We determine the added value of immersive virtual reality (VR) in accurately assessing LAA base size and selection of an appropriately sized clip. Methods: We studied the feasibility of measuring the LAA base using VR and conventional computed tomography (CT). A retrospective analysis was performed of LAA base measurements in 15 patients who had undergone thoracoscopic LAA clipping. Subsequently, we compared the placed clip size with imaging-acquired LAA base size to retrospectively evaluate intraprocedural sizing. Results: We successfully applied a VR platform to measure LAA base size. The median LAA base size measured in CT (23.8 mm, interquartile range [IQR] 22.3 to 26.4 mm) and intracardial virtual reality (23.4 mm, IQR 21.6 to 25.5 mm) did not differ significantly (P = 0.416). VR measurements of the LAA base in surgeon's view (25.7 mm, IQR 24.2 to 29.2) were significantly higher than those of 2-dimensional CT (P = 0.037) and intracardial 3-dimensional (3D) VR (P < 0.05) measurements. All measurements differed significantly with placed clip sizes (P < 0.05). There were no clip malpositioning-related events. Conclusions: Immersive VR is a feasible method for obtaining anatomical information on LAA base size. In this retrospective analysis, CT and VR-based measurements of LAA base size differed significantly from intraoperatively placed LAA clips, indicating potential oversizing when measured intraoperatively. Using intuitive 3D VR-based imaging might be a useful method to assist in accurate preprocedural sizing of LAA base and can potentially prevent oversizing.

Long-Term Efficacy and Anticoagulation Strategy of Left Atrial Appendage Occlusion During Total Thoracoscopic Ablation of Atrial Fibrillation to Prevent Ischemic Stroke.

ObjectivesAtrial fibrillation (AF) is associated with an increased ischemic stroke, and the left atrial appendage (LAA) represents the main source of thrombus formation. We evaluated the long-term efficacy of surgical thoracoscopic LAA occlusion during total thoracoscopic ablation of AF to prevent the stroke and anticoagulation strategy after surgery.MethodsPatients who underwent total thoracoscopic ablation for AF, from February 2012 to May 2020, were included; Patients who did not receive LAA occlusion were excluded. We evaluated the development of thromboembolism in these patients.ResultsThe total number of 460 patients [mean age, 57.1 ± 9.2 years; 400 (87.0%) males] were included in the study. The mean follow-up duration was 44.8 months. The mean CHA2DS2-VASc score was 1.9 ± 1.6. Median OAC duration was 109.5 days after the surgery, and the final number of patients who discontinued OAC were 411 (89.3%) in total. Anticoagulation discontinuation rate according to CHA2DS2-VASc score are as follows; (i) 0 = 99.0%; (ii) 1 = 98.2%; and (iii) ≥2 = 81.3%. The annualized incidence rate of ischemic stroke was 0.78%/year, showing a 73% risk reduction compared with the CHA2DS2-VASc predicted rate without anticoagulation. The hazard ratio for ischemic stroke according to previous stroke history was 1.5 [95% confidential interval (CI) 0.3–7.3, p = 0.62], and that of remnant LAA was 5.1 (1.2–20.9, p = 0.02).ConclusionsThoracoscopic LAA occlusion during total thoracoscopic ablation of AF was effective to prevent ischemic stroke. Most patients could discontinue OAC therapy after the procedure. Patients who had a residual trabeculated LAA, or peri-occluder pouch in follow-up CT need to maintain OAC therapy even after LAA occlusion.

Left atrial function after standalone totally thoracoscopic left atrial appendage exclusion in af patients with absolute contraindication to oral anticoagulation therapy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left atrial appendage (LAA) is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). The Totally Thoracoscopic (TT) LAA exclusion with epicardial clip has become a safe and effective procedure, but the effect on left atrial (LA) function remains unknown. Purpose The aim of this study was to assess the effect of TT LAA exclusion on LA function. Methods 20 patients (15 males) with non-valvular AF and contraindication to oral anticoagulation therapy (OAT) or antiplatelet therapy underwent standalone TT LAA exclusion with the Atriclip Pro II device. All patients were screened preoperatively with 3D CT scan, trans-esophageal echocardiography, spirometry and cerebrovascular doppler ultrasound. Intraoperative Atriclip Pro II positioning and LAA exclusion were guided and confirmed by trans-esophageal echo. To objectify LA function, transthoracic echocardiography with 2D Speckle tracking was performed before surgery, at discharge and at 3-month follow-up. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit. Results Baseline characteristics are reported in Table I. There were no major complications during the procedures. One non cardiovascular death, one minor stroke and 4 hospitalizations occur at 1-year follow up. The reservoir LA function considering the strain measurements dramatically decreased few days after the procedure and it recovered at 3-month follow-up compared to baseline, even though the LA volume is augmented (Table II). Furthermore, NT pro-BNP increased and ventricular strain decreased significantly after the procedure recovering over time. Conclusion TT LAA exclusion with Atriclip Pro II device is a safe and effective procedure in preventing AF related stroke in patients with contraindication to OAT. Our findings suggest that the LAA epicardial clip impairs immediately the reservoir LA function that recovers over time. Abstract Table I Abstract Table II

Electrical Isolation Following Thoracoscopic Left Atrial Appendage Exclusion During Hybrid Ablation for Longstanding Persistent Atrial Fibrillation

Electrical Isolation Following Thoracoscopic Left Atrial Appendage Exclusion During Hybrid Ablation for Longstanding Persistent Atrial Fibrillation

Minimally invasive thoracoscopic left atrial appendage occlusion compared with transcatheter left atrial appendage closure for stroke prevention in recurrent nonvalvular atrial fibrillation patients after radiofrequency ablation: a prospective cohort study.

BACKGROUNDTanscatheter left atrial appendage (LAA) closure and minimally invasive thoracoscopic LAA occlusion are local interventions of LAA for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, the safety and efficacy of these methods have not been compared. This prospective cohort study aimed to assess the safety and efficacy of those two treatment approaches for stroke prevention in NVAF patients.METHODSTwo hundred and nine recurrent NVAF patients who received radiofrequency ablation were enrolled. These patients were treated with transcatheter LAA closure or thoracoscopic LAA occlusion. The patients were followed up from the first postoperative day and evaluated for efficacy endpoints (stroke/transient ischemic attack (TIA), systemic embolism (SE), and death) and a safety endpoint (bleeding events). Perioperative complications were recorded.RESULTSAfter a median follow-up of 1.8 years (383 patient-years), the overall rate of the composite efficacy endpoints was similar between the two groups (3.8 vs. 2.7 events per 100 patient-years; HR = 0.71; 95% CI: 0.225−2.237; P = 0.559). However, regarding primary safety endpoint, there were 1.5 bleeding events per 100 patient-years in the thoracoscopic LAA occlusion group, compared with 6.4 in transcatheter LAA closure group (HR = 0.246; 95% CI: 0.074−0.819; P = 0.022). The incidence of operative complications was 3/138 (2.17%) in thoracoscopic LAA occlusion group and 1/71 (1.41%) in transcatheter LAA closure group. CONCLUSIONSThoracoscopic LAA occlusion and transcatheter LAA closure have similar efficacy in preventing stroke in NVAF patients. However, the thoracoscopic group had fewer bleeding events than the transcatheter group, but the former group required a longer hospital stay.

Abstract 11056: Thoracoscopic Left Atrial Appendage Occlusion with Atriclip TM : An Initial Experience

Introduction: Left atrial appendage (LAA) closure is an important tool in stroke prevention. Totally thoracoscopic LAA closure using the AtriClip™ device avoids intracardiac components, although early outcomes have not been systematically documented. Methods and Results: 105 consecutive fully thoracoscopic AtriClip TM procedures were examined, involving 84(80%) males, 21(20%) females and mean (+/- SD) age 70.1+/-9.2 years. The most common indication was as part of an AF ablation procedure (n=38, 36.2%), or anticoagulation-related hemorrhage (n=27, 25.7%). Median (interquartile range, IQR) CHADS 2 VaSc = 3 (2-4) and HAS-BLED = 3 (1-3). Half the patients (n=51, 48.6%) underwent isolated AtriClip insertion, 90% had a size 40 or 45mm AtriClip device, and none experienced circumflex coronary artery or phrenic nerve compromise. Intraprocedural transesophageal echocardiography demonstrated complete occlusion in all patients. Follow-up at 6 weeks with CT or transesophageal echocardiography confirmed occlusion in all patients (79% follow-up). The length of stay for isolated thoracoscopic AtriClip TM was 3 days (IQR 2-4) with longer admissions due to unrelated conditions (e.g. heart failure, AF or chest infection). No cases of LAA perforation were recorded and no patients with isolated AtriClip required transfusion. Transient pericarditis occurred in 10 patients (9.5%, 5 requiring readmission within 30 days) with a pericardial effusion in 3 patients (2.9%, requiring pericardiocentesis in one patient). No strokes occurred and 93% of isolated Atriclip patients had ceased anticoagulation at 30 days. Conclusions: Total thoracoscopic LAA closure using the AtriClip device is safe and effective. The most common complication is transient pericarditis (9.5%) and major complications were not seen.

Thoracoscopic Left Atrial Appendage Ligation Complicated by Persistent Left Superior Vena Cava

We herein report a 64 year-old male who had an incidental finding of a persistent left superior vena cava (SVC) revealed by intraoperative transesophageal echocardiography (TEE) during a Maze procedure with left atrial appendage ligation. During the intraoperative TEE, an incidental dilated coronary sinus > 1.1 cm was noted which prompted further evaluation and aided in our ultimate diagnosis. Consequently, significant additional surgical dissection and manipulation were required to isolate the left upper pulmonary vein. This case report reviews the anatomy and embryology of a persistent left SVC, discusses its clinical implications, and identifies surgical considerations for treatment.

Single-Incision Thoracoscopic Left Atrial Appendage Ligation: First Reported Experience.

Atrial fibrillation is an increasingly prevalent entity faced by cardiac surgeons. While oral anticoagulation therapy aims to reduce the risk of thromboembolic events patients may desire to discontinue these medications or develop contraindications to their use. Left atrial appendage ligation permits stoppage of oral anticoagulation while also reducing the risk of cerebrovascular events. This manuscript describes the techniques employed in the first reported successful uniportal/single-incision, thoracoscopic epicardial left atrial appendage ligation.

Stand-Alone Thoracoscopic Left Atrial Appendage Closure in Nonvalvular Atrial Fibrillation Patients at High Bleeding Risk.

In nonvalvular atrial fibrillation (AF) patients at high bleeding risk, oral anticoagulants (OAC) may be contraindicated, and percutaneous left atrial appendage (LAA) closure has been advocated. However, following percutaneous procedure, either OAC or dual antiplatelet treatment is required. In this study, we present our experience in treating nonvalvular AF patients at high bleeding risk with thoracoscopic LAA closure with no subsequent antithrombotic therapy. From April 2019 to January 2020, 20 consecutive AF patients, mean age 75.1 years, 16 (80%) males, underwent thoracoscopic LAA closure as a stand-alone procedure, using an epicardial clip device. OAC and antiplatelet therapy were contraindicated. Mean CHA2DS2-VASc score was 3.61, and the mean HAS-BLED score was 4.42. Successful LAA closure was assessed by transesophageal echocardiography. Primary endpoints were complete LAA closure (no residual LAA flow), operative complications, and all-cause mortality; secondary endpoints were 30-day and 6-month complications (death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, any bleeding). Mean follow-up was 6 ± 4 months. Complete LAA closure was achieved in all patients. No operative clip-related complications or deaths occurred. At follow-up, freedom from postoperative complications was 95% and from any cerebrovascular events was 100%. Overall survival rate was 100%. In nonvalvular AF patients at high bleeding risk (HAS-BLED score >3), thoracoscopic LAA closure appears to be a valid alternative to percutaneous techniques not requiring dual antiplatelet or OAC treatment. Apparently, external LAA clipping minimizes the risk of thromboembolic events as compared with percutaneous procedures.