Epicardial standalone left atrial appendage clipping for prevention of ischemic stroke in patients with atrial fibrillation contraindicated for oral anticaogulation

Abstract

IntroductionThe most appropriate treatment for stroke prevention in standalone atrial fibrillation patients with a high CHADS2VASC score contraindicated for oral anticoagulation (OAC) or novel OAC (NOAC) still needs to be defined. Percutaneous left atrial appendage (LAA) closure devices are available, but because of their endocardial positioning need a period of antiplatelet therapy (APT). This study aimed to evaluate the safety and efficacy of epicardial left atrial appendage clipping in patients contraindicated for (N)OAC and APT.Methods and ResultsWe describe a standalone totally thoracoscopic LAA clipping of forty‐five consecutive patients with nonvalvular atrial fibrillation (NVAF; 32 males; age, 73.1 ± 7.4 years; CHADVASC, 6.5 ± 1.1; HAS‐BLED 4.9 ± 0.9) with absolute contraindications to (N)OAC. The patients were selected by a multidisciplinary Heart Team. Sixty percent had a previous ischemic stroke and 51% a history of the hemorrhagic event and 22% both. All patients were implanted with an LAA epicardial clip, guided by preoperative computed tomography and intraoperative transesophageal echocardiography. The mean procedural duration was 52.3 ± 12.6 minutes with postprocedural extubation interval of 22.8 ± 14.6 minutes. No procedure‐related complications occurred. Intraprocedural transesophageal echocardiography (TEE) showed complete LAA occlusion in all patients. At a mean follow‐up of 16.4 ± 9.1 months (range, 2‐34), with all patients off (N)OAC or APT, no ischemic stroke or hemorrhagic complications occurred. computed tomography or TEE at follow‐up demonstrated a correct LAA occlusion in all with mean stumps of 3.3 ± 2.8 mm.ConclusionThoracoscopic epicardial closure of the LAA with the AtriClip PRO2 device is a potentially safe and efficient treatment for stroke prevention in patients with NVAF contraindicated for anticoagulant therapy or APT.

Robotics-assisted epicardial left atrial appendage clip exclusion

“…That requirement might temporarily increase the risk of bleeding after implantation, especially in patients with severe and unidentified sources of gastrointestinal bleeding or intracranial bleeding. 14 , 15 , 16 Some LAA anatomical variations might also limit the pool of beneficiaries of endocardial LAA occluders. The development of our program was in response to some of those needs and challenges.…”

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

“…Additionally, no clip migration or device-related complications have been reported in these reports. 5,6…”

Electrical Isolation of the Left Atrial Appendage - A New Frontier in the Treatment for Atrial Fibrillation

“…Subsequently, many studies have been conducted to show the high levels of success and safety in deploying the AtriClip device, including a recent systematic review of 11 studies by Toale et al [53]. At present, there is a current lack of adequately powered, prospective, randomised studies to accurately assess the reduction in risk of stroke with the use of the AtriClip; however, there is very encouraging evidence from smaller-scale or non-randomised studies, a large registry study, and a systematic review [42,[53][54][55][56].…”