The Effect of Minimally Invasive Thoracoscopic Left Atrial Appendage Excision on Cardiac Dynamic and Endocrine Function

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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Patient-specific catheter shaping for the minimally invasive closure of the left atrial appendage

International Journal of Computer Assisted Radiology and Surgery ◽

10.1007/s11548-018-1752-4 ◽

2018 ◽

Vol 13 (6) ◽

pp. 837-846

Author(s):

Eva C. Graf ◽

Ilka Ott ◽

Julian Praceus ◽

Felix Bourier ◽

Tim C. Lueth

Keyword(s):

Minimally Invasive ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Patient Specific

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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 ◽

10.1177/155698451701200106 ◽

2017 ◽

Vol 12 (1) ◽

pp. 28-32

Author(s):

Nathan E. Smith ◽

Jeevan Joseph ◽

John Morgan ◽

Saqib Masroor

Keyword(s):

Minimally Invasive ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Initial Experience ◽

Minimally Invasive Surgical

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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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New Approach to Exclude the Left Atrial Appendage during Minimally Invasive Cryothermic Surgical Ablation

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000179 ◽

2015 ◽

Vol 10 (5) ◽

pp. 323-327 ◽

Cited By ~ 11

Author(s):

Niv Ad ◽

Paul S. Massimiano ◽

Deborah J. Shuman ◽

Graciela Pritchard ◽

Sari D. Holmes

Keyword(s):

Minimally Invasive ◽

Left Atrial ◽

Left Atrial Appendage ◽

Transverse Sinus ◽

Current Approach ◽

Atrial Appendage ◽

Perioperative Outcomes ◽

Surgical Ablation ◽

New Approach ◽

Increased Risk

Objective Atrial fibrillation (AF) is associated with an increased risk for embolic stroke originating from the left atrial appendage (LAA). A recently introduced LAA epicardial clip occluder, the AtriClip PRO, can be applied through midsternotomy or small thoracotomy. We assessed the safety and efficacy of a new surgical approach to apply the AtriClip PRO and exclude the LAA through right minithoracotomy and transverse sinus. Methods The AtriClip PRO was applied in 24 patients with the new approach. Intraoperative transesophageal echocardiography was used to exclude LAA thrombi at baseline and evaluate LAA perfusion and residual neck postoperatively. Results Mean (SD) age was 64.5 (8.6) years; 95% of the patients had nonparoxysmal AF with median AF duration of 39 months (interquartile range, 9.3–85.3 months), and mean (SD) left atrium diameter was 4.5 (0.7) cm (range, 3.1–5.7 cm). In one attempt, the clip was not deployed because of severe adhesions in the transverse sinus area. The procedural success rate was 95%. Nine minimally invasive mitral valve repairs were combined with surgical ablation; the rest were isolated right minithoracotomy Cox maze procedures. There was no remaining LAA neck in 71% of the patients. Perioperative outcomes were acceptable, and median length of stay was 5.5 days. Conclusions The development of a reliable approach to LAA management during minimally invasive surgical ablation through right minithoracotomy has been challenging. This new approach is safe and effective and should offer a superior and consistent early and long-term solution compared with the current approach of endocardial stitch closure.

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