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

2017 ◽  
Vol 12 (1) ◽  
pp. 28-32 ◽  
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.

scholarly journals Comparison of Left Atrial Appendage Occlusion versus Non-Vitamin-K Antagonist Oral Anticoagulation in High-Risk Atrial Fibrillation: An Update

2021 ◽  
Vol 8 (6) ◽  
pp. 69
Author(s):  
Shaojie Chen ◽  
K. R. Julian Chun ◽  
Zhiyu Ling ◽  
Shaowen Liu ◽  
Lin Zhu ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
High Risk ◽  
Vitamin K ◽  
Major Bleeding ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Vitamin K Antagonists ◽  
Left Atrial Appendage Occlusion ◽  
The Mean

Transcatheter left atrial appendage occlusion (LAAO) is non-inferior to vitamin K antagonists (VKAs) in preventing thromboembolic events in atrial fibrillation (AF). Non-vitamin K antagonists (NOACs) have an improved safety profile over VKAs; however, evidence regarding their effect on cardiovascular and neurological outcomes relative to LAAO is limited. Up-to-date randomized trials or propensity-score-matched data comparing LAAO vs. NOACs in high-risk patients with AF were pooled in our study. A total of 2849 AF patients (LAAO: 1368, NOACs: 1481, mean age: 75 ± 7.5 yrs, 63.5% male) were enrolled. The mean CHA2DS2-VASc score was 4.3 ± 1.7, and the mean HAS-BLED score was 3.4 ± 1.2. The baseline characteristics were comparable between the two groups. In the LAAO group, the success rate of device implantation was 98.8%. During a mean follow-up of 2 years, as compared with NOACs, LAAO was associated with a significant reduction of ISTH major bleeding (p = 0.0002). There were no significant differences in terms of ischemic stroke (p = 0.61), ischemic stroke/thromboembolism (p = 0.63), ISTH major and clinically relevant minor bleeding (p = 0.73), cardiovascular death (p = 0.63), and all-cause mortality (p = 0.71). There was a trend toward reduction of combined major cardiovascular and neurological endpoints in the LAAO group (OR: 0.84, 95% CI: 0.64–1.11, p = 0.12). In conclusion, for high-risk AF patients, LAAO is associated with a significant reduction of ISTH major bleeding without increased ischemic events, as compared to “contemporary NOACs”. The present data show the superior role of LAAO over NOACs among high-risk AF patients in terms of reduction of major bleeding; however, more randomized controlled trials are warranted.

Abstract 14990: Pulmonary Vein Stenosis After Epicardial Atrial Fibrillation Ablation and Epicardial Left Atrial Appendage Occlusion: A Diagnostic Dilemma and Challenges in Management

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Moghniuddin Mohammed ◽  
Nachiket Apte ◽  
Mohammed Ansari ◽  
Amit Noheria ◽  
Seth Sheldon ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Atrial Appendage ◽  
Maze Procedure ◽  
Pulmonary Vein Stenosis ◽  
Epicardial Ablation ◽  
Left Atrial Appendage Occlusion ◽  
Vein Stenosis

Background: Pulmonary vein stenosis is a dreaded complication of endocardial atrial fibrillation (AF) ablation but rare after epicardial ablation and has not been reported after epicardial left atrial appendage occlusion (LAAO). Case: A 55-year-old male was referred to our tertiary hospital for management of left superior pulmonary vein (LSPV) stenosis causing dyspnea on exertion. About 2 years prior to presentation, he underwent quadruple coronary artery bypass grafting for non-ST elevation myocardial infarction along with modified Cox-Maze procedure with pulmonary vein and posterior wall isolation as well as epicardial LAAO with AtriClip for history of paroxysmal AF. At our institute, V/Q scan showed ventilation-perfusion mismatch and absent perfusion of the left upper lobe (Figure 1A). Cardiac CT showed persistent LSPV occlusion (Figure 1B). TEE showed atrial appendage occluded with a clip and no flow was observed from LSPV (Figure 1C). After multidisciplinary discussion between cardiology and cardiothoracic surgery teams, surgical approach to remove the AtriClip was deemed futile as it was placed 2 years ago and less likely to result in resolution of stenosis. Thus, an endovascular approach was attempted with left atrial and pulmonary vein angiography showing LSPV to be 100% occluded (Figure 1D). Pulmonary vein recanalization was attempted but was not successful. Conclusion: Our case highlights the importance of recognition of PVS as a possible complication after epicardial LAAO as early intervention can improve patient outcomes. PVS has been previously described with Maze procedure but that patient was successfully treated with catheter-balloon angioplasty. Given 100% occlusion and difficulty with recanalization makes epicardial ablation a less likely cause of occlusion in our case. More careful application of Atriclip protocols might be necessary to prevent this potential complication.

Surgical Treatment of Isolated (Lone) Atrial Fibrillation with Gemini-S Ablation and Left Atrial Appendage Excision (GALAXY Procedure)

2012 ◽  
Vol 7 (1) ◽  
pp. 33-38 ◽  
Author(s):  
John R. Doty ◽  
Stephen E. Clayson
Keyword(s):  
Atrial Fibrillation ◽  
Minimally Invasive ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Persistent Atrial Fibrillation ◽  
Atrial Appendage ◽  
Lone Atrial Fibrillation ◽  
Surgical Ablation ◽  
Invasive Approach ◽  
The Galaxy

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.

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

2012 ◽  
Vol 7 (3) ◽  
pp. 195-200 ◽  
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.

Prognostic Value of Low Left Atrial Appendage Wall Velocity in Patients with Ischemic Stroke and Atrial Fibrillation

2012 ◽  
Vol 25 (5) ◽  
pp. 576-583 ◽  
Author(s):  
Harutoshi Tamura ◽  
Tetsu Watanabe ◽  
Satoshi Nishiyama ◽  
Shintaro Sasaki ◽  
Masahiro Wanezaki ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Left Atrial ◽  
Prognostic Value ◽  
Left Atrial Appendage ◽  
Atrial Appendage ◽  
Wall Velocity
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