Early operative comparison of two epicardial left atrial appendage occluding systems applied during off-pump coronary revascularisation in patients with persistent atrial fibrillation

Abstract

IntroductionAtrial fibrillation (AF) increases long-term mortality and stroke rate in patients having coronary artery bypass grafting (CABG). Because oral anticoagulation (OAC) is associated with both a significant incidence of discontinuation and well known complication rates, left atrial appendage occlusion might be beneficial for stroke prevention. This study presents the first clinical and practical comparison of two epicardial left appendage occluders (LAAO) accruing experience in application during off-pump coronary revascularisation in patients with persistent AF.Material and methodsFifteen consecutive patients with persistent AF were assigned to intraoperative LAA occlusion with either TigerPaw System II (n = 8) or AtriClip (n = 7) device during off-pump CABG and concomitant left atrial epicardial ablation. Both systems were analysed in terms of ease and safety of application along with intraoperative LAA occlusion success.ResultsSurgical risk was increased in the study population (mean EuroScore II: 3.2 ± 0.3%). In all patients in the AtriClip group successful off-pump LAA occlusion confirmed by intraoperative transoesophageal echocardiography was achieved. The TigerPaw application was quicker and easier, but in 2 patients it was unsuccessful. During the hospital stay there were no bleeding or thromboembolic events recorded.ConclusionsIn a pilot cohort epicardial LAAO during off-pump CABG in patients with persistent AF was performed safely and successfully with an AtriClip device. The TigerPaw System requires technological improvement. It might be useful to adapt the use of the type of occluding device to the LAA morphologic type and target revascularisation vessels to avoid the additional use of a heart positioner or obviate coronary compression.

Research Opportunities in Stroke Prevention for Atrial Fibrillation: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop

“…69 Multiple disparate techniques have been used for surgical LAA closure, which currently has a Class IIB recommendation, 21,22 and the technique used is critical, with a wide range of reported complete LAA closure (0% staple closure, 23% suture closure, 73% excision, and >90% clip closure). [70][71][72] Several observational studies suggest surgical LAA closure/excision may be associated with lower rates of thromboembolism, which may be more prominent in those with prior history of AF, but the procedure may also be associated with a higher rate of incident AF after surgery. [73][74][75] To date, most RCTs have been small and underpowered to assess clinical outcomes.…”

“…69 Multiple disparate techniques have been used for surgical LAA closure, which currently has a Class IIB recommendation, 21,22 and the technique used is critical, with a wide range of reported complete LAA closure (0% staple closure, 23% suture closure, 73% excision, and >90% clip closure). 70–72…”

Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke

“…Finally, patients at different risks for developing stroke were included in the single studies and thus the meta-analysis; only half of the studies provided CHA 2 DS 2 VASc score, 6 studies provided information regarding OAC at baseline, 12 provided information regarding OAC at discharge, and 3 provided information on OAC compliance at follow-up, making the associations of LAAC with reduced mortality limited. On the other hand, we conducted a series of sensitivity analyses, including those accounting for durations of follow-up and excluding observational nonadjusted studies, E21 , E22 , E23 , E24 , E25 , E26 , E27 , E28 , E29 , E30 , E31 , E32 , E33 , E34 , E35 , E36 , E37 , E38 , E39 , E40 , E41 , E42 , E43 , E44 , E45 , E46 , E47 , E48 , E49 , E50 , E51 , E52 , E53 , E54 and found the direction and magnitude of estimates to support the main results.…”

Pharmacological and Non-pharmacological Treatments for Stroke Prevention in Patients with Atrial Fibrillation

“…Another method for LAA occlusion during cardiac surgery is a clip device (“AtriClip”) that is placed epicardially at the base of the left atrial appendage. Study reports from the “EXCLUDE” (Exclusion Device in Patients Undergoing Concomitant Cardiac Surgery) trial suggested a fast, atraumatic, and highly successful left atrial appendage occlusion [ 131 ], and possible application of the device in off-pump surgery has been shown very recently [ 132 ]. Another recently developed tool favors access via mini-thoracotomy and occluding LAA via a clamp consisting of two tubes connected by an elastic bow [ 133 ].…”