Minimally Invasive Left Atrial Appendage Excision and Atrial Fibrillation Ablation as Secondary Prevention of Thromboembolic Stroke—Weighing the Risk Versus the Benefit

Objective Surgical ablation with radiofrequency is a safe and effective treatment for atrial fibrillation. Recent advances in instrumentation have allowed for the application of bipolar radiofrequency through a minimally invasive approach using small bilateral thoracotomies for pulmonary vein isolation, destruction of autonomic ganglia, and excision of the left atrial appendage (GALAXY procedure). Methods Thirty-two patients underwent surgical ablation of atrial fibrillation with the GALAXY procedure over a 43-month period. Data were collected in a prospective manner during hospitalization and at 1-, 3-, 6-, and 12-month intervals for rhythm, medications, and subsequent interventions. Results There were no operative mortality, no myocardial infarction, and no stroke. One patient required reexploration for bleeding. Mean follow-up was 28 months (range, 4–43 months). Freedom from atrial fibrillation at 12 and 24 months, respectively, was 90% and 67% for patients with paroxysmal fibrillation and 80% and 63% for patients with persistent atrial fibrillation. Of the patients who were not in sinus rhythm, four reverted to atrial fibrillation and two reverted to atrial flutter. Conclusions The GALAXY procedure is a safe and effective, minimally invasive method for treatment of isolated (lone) atrial fibrillation. The operation provides excellent short-term freedom from atrial fibrillation and should be considered in patients with isolated paroxysmal atrial fibrillation.

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Left Atrial Appendage Occlusion Pilot Study of a Fourth-Generation, Minimally Invasive Device

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e3182618feb ◽

2012 ◽

Vol 7 (3) ◽

pp. 195-200 ◽

Cited By ~ 2

Author(s):

Hideyuki Fumoto ◽

A. Marc Gillinov ◽

Roberto M. Saraiva ◽

Tetsuya Horai ◽

Tomohiro Anzai ◽

...

Keyword(s):

Atrial Fibrillation ◽

Coronary Angiography ◽

Minimally Invasive ◽

Left Atrial ◽

Left Atrial Appendage ◽

Therapeutic Option ◽

Median Sternotomy ◽

Atrial Appendage ◽

Fourth Generation ◽

Left Circumflex Artery

Objective Exclusion of the left atrial appendage is proposed to reduce the risk of stroke in patients with atrial fibrillation. The aim of this study was to evaluate the feasibility and efficacy of a fourth-generation atrial exclusion device developed for minimally invasive applications. Methods The novel atrial exclusion device consists of two polymer beams and two elastomeric bands that connect the two beams at either end. Fifteen mongrel dogs were implanted with the device at the base of the left atrial appendage through a median sternotomy and were evaluated at 30 (n = 7), 90 (n = 6), and 180 (n = 2) days after implantation by epicardial echocardiography, left atrial and coronary angiography, gross pathology, and histology. Results Left atrial appendage exclusion was completed without hemodynamic instability. Coronary angiography revealed that the left circumflex artery was patent in all cases. A new endothelial tissue layer developed, as expected, on the occluded orifice of the left atrium. Conclusions This novel atrial exclusion device achieved easy, reliable, and safe exclusion of the left atrial appendage, with favorable histological results in a canine model for up to 6 months. Clinical application could provide a new therapeutic option for reducing the risk of stroke in patients with atrial fibrillation.

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Initial Experience with Minimally Invasive Surgical Exclusion of the Left Atrial Appendage with an Epicardial Clip

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000339 ◽

2017 ◽

Vol 12 (1) ◽

pp. 28-32 ◽

Cited By ~ 3

Author(s):

Nathan E. Smith ◽

Jeevan Joseph ◽

John Morgan ◽

Saqib Masroor

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Minimally Invasive ◽

Left Atrial ◽

Left Atrial Appendage ◽

Intercostal Space ◽

Atrial Appendage ◽

Maze Procedure ◽

Initial Experience ◽

The Mean

Objective Atrial fibrillation (AF) is the primary cardiac abnormality associated with ischemic stroke. Atrial fibrillation affects 2.7 million people with a stroke rate of 3.5% per year. Most of the emboli in patients with nonvalvular AF originate in the left atrial appendage (LAA). Surgical exclusion of the LAA decreases the yearly risk of stroke to 0.7% when combined with a Maze procedure. Traditional oversewing the LAA from inside the left atrium is associated with a significant number of recanalizations of LAA. An alternate technique is epicardial clipping, which has been approved through sternotomy for permanent exclusion of LAA. We present our initial experience of epicardial clipping of the LAA using a minimally invasive approach. Methods Between May 2012 and December 2015, a total of 24 consecutive patients underwent minimally invasive, echo-guided epicardial clipping. Indications for the procedure were persistent (n = 12) or paroxysmal (n = 12) AF in patients who could not tolerate full anticoagulation because of a combination of gastrointestinal bleeding (n = 7), hemorrhagic stroke (n = 5), ischemic stroke (n = 5), intramuscular bleeding (n = 3), falls (n = 2), urinary tract bleeding (n = 2), subdural hematoma (n = 1), traumatic aortic intramural hematoma (n = 1), and lifestyle and career practices inconsistent with anticoagulation (n = 1). The clipping was performed through three 5-mm ports in the left seventh intercostal space (n = 22) or a 5-cm incision in the fifth intercostal space (n = 2). Echocardiography was performed to exclude the presence of LAA thrombus and to confirm exclusion of LAA before final deployment of the clip. Results The mean age was 73.6 years. The mean CHA2DS2VASC score was 4.7 and the mean HAS-BLED score was 3.8. The mean postoperative length of stay was 6.4 days. One patient died of stroke-related complications 10 days after successful clipping, and two patients required thoracentesis to drain recurrent pleural effusions. All patients had successful exclusion of LAA defined as residual sac of less than 1 cm. Conclusions Isolated epicardial left atrial clipping is a safe treatment option in high-risk patients with AF. Long-term success in preventing stroke is still to be determined, but short-term results are very encouraging.

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Concomitant atrial fibrillation ablation and left atrial appendage occlusion using Amplatzer devices – a single centre experience

Cardiovascular Medicine ◽

10.4414/cvm.2020.02130 ◽

2020 ◽

Author(s):

Samuel Hannes Baldinger ◽

Eleni Goulouti ◽

Michael Schmid ◽

Samera Shakir ◽

Laurent Roten ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Fibrillation Ablation ◽

Atrial Appendage ◽

Single Centre ◽

Left Atrial Appendage Occlusion ◽

Single Centre Experience

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Left atrial appendage occlusion: an alternative to anticoagulation for stroke prevention in kidney disease

Kidney360 ◽

10.34067/kid.0004082021 ◽

2021 ◽

pp. 10.34067/KID.0004082021

Author(s):

Srikanth Vallurupalli ◽

Tanya Sharma ◽

Subhi Al'Aref ◽

Subodh R. Devabhaktuni ◽

Gaurav Dhar

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Stroke Risk ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

High Risk Population ◽

Thromboembolic Stroke ◽

Nonvalvular Atrial Fibrillation ◽

Left Atrial Appendage Occlusion ◽

Pros And Cons

Anticoagulation to reduce thromboembolic stroke risk due to nonvalvular atrial fibrillation in ESRD is associated with increased bleeding. Existing debate in ESRD centers around the pros and cons of anticoagulation. We propose percutaneous left atrial appendage occlusion as a third alternative to balance thrombosis and bleeding risks in this high risk population.

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