Standalone epicardial left atrial appendage exclusion for thromboembolism prevention in atrial fibrillation

Abstract

OBJECTIVES Most strokes associated with atrial fibrillation (AF) result from left atrial appendage thrombi. Oral anticoagulation can reduce stroke risk but is limited by complication risk and non-compliance. Left atrial appendage exclusion (LAAE) is a new surgical option to reduce stroke risk in AF. The study objective was to evaluate the safety and feasibility of standalone thoracoscopic LAAE in high stroke risk AF patients. METHODS This was a retrospective, multicentre study of high stroke risk AF patients who had oral anticoagulation contraindications and were not candidates for ablation nor other cardiac surgery. Standalone thoracoscopic LAAE was performed using 3 unilateral ports access and epicardial clip. Periprocedural adverse events, long-term observational clinical outcomes and stroke rate were evaluated. RESULTS Procedural success was 99.4% (174/175 patients). Pleural effusion occurred in 4 (2.3%) patients; other periprocedural complications were <1% each. One perioperative haemorrhagic stroke occurred (0.6%). No phrenic nerve palsy or cardiac tamponade occurred. Predicted annual ischaemic stroke rate of 4.8/100 patient-years (based on median CHA2DS2-VASc score of 4.0) was significantly higher than stroke risk observed in follow-up after LAAE. No ischaemic strokes occurred (median follow-up: 12.5 months), resulting in observed rate of 0 (95% CI 0–2.0)/100 patient-years (P < 0.001 versus predicted). Six all-cause (non-device-related) deaths occurred during follow-up. CONCLUSIONS Study proved that a new surgical option, standalone thoracoscopic LAAE, is feasible and safe. With this method, long-term stroke rate may be reduced compared to predicted for high-risk AF population.

Optimal Therapy for Stroke Prevention in Atrial Fibrillation: Is it Left Atrial Appendage Closure?

“…1 The total number of subjects in these studies is 442 patients. [9][10][11] This is less than aforementioned randomized Watchman trials which enrolled 707 patients in the PROTECT AF, 407 patients in PREVAIL, and 402 patients in PRAGUE-17. Even these studies enrolled many fewer patients than the seminal trials of DOACs versus warfarin: 18,133 in RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) 12 , 14,264 in ROCKET-AF (Rivoxaraban Once Daily Oral Direct Factor XA Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) 13 , 18,201 patients in ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) 14 , and 21,105 patients in ENGAGE AF-TIMI 48 (The Effective Anticoagulation with a Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) 15 for a total of 71,703 patients.…”

The Convergent procedure for AF: A surgeon's perspective

“…13 It therefore seems reasonable that during a "concomitant" ablation, such as the subxiphoid Convergent approach, the LAA be managed. In this scenario, a VATS or thoracoscopically placed AtriClip™ is well suited to accomplish this goal and this has been shown to be readily accomplished in prospective cohort studies with excellent results (>95% occlusion without devicerelated thrombus or flow) [15][16][17] (Figure 3).…”

Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective

“…Epicardial LAAO because of the absence of a foreign material inside the heart potentially does not require any antithrombotic therapy, addressing some anatomical, procedural, and clinical issues improving bleeding outcomes. Only few reports with this approach are published and all have a post procedure period of antithrombotic therapy [ 16 , 17 , 18 , 19 ]. Here, we describe our experience regarding the safety and efficacy of standalone totally thoracoscopic epicardial appendage clipping with immediate antithrombotic discontinuation.…”