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Published on: February 26, 2013
Initial Experience With Minimally Invasive Surgical Exclusion of the Left Atrial Appendage With an Epicardial Clip
Nathan E Smith1, Jeevan Joseph, John Morgan
1From the Mercy Hospital and Kendall Regional Medical Center, Florida Heart and Vascular Care, Miami, FL USA; and Aventura Medical Center, Aventura, FL USA.
Insights
Minimally invasive epicardial clipping safely excludes the left atrial appendage (LAA) in high-risk atrial fibrillation (AF) patients, reducing stroke risk. Short-term results show successful LAA exclusion, though long-term stroke prevention efficacy requires further study.
Area of Science:
- Cardiology
- Minimally Invasive Surgery
- Stroke Prevention
Background:
- Atrial fibrillation (AF) is a primary cause of ischemic stroke, with most emboli originating from the left atrial appendage (LAA).
- Traditional LAA occlusion methods have limitations, including recanalization, necessitating alternative approaches.
- Epicardial clipping offers a permanent LAA exclusion method, previously approved via sternotomy.
Purpose of the Study:
- To evaluate the initial experience and safety of minimally invasive, echo-guided epicardial clipping of the LAA.
- To assess the feasibility of this approach in patients with AF who cannot tolerate anticoagulation.
Main Methods:
- Twenty-four consecutive patients with persistent or paroxysmal AF underwent minimally invasive epicardial clipping between May 2012 and December 2015.
- Indications included contraindications to anticoagulation due to bleeding events or stroke history.
- The procedure utilized three 5-mm ports or a small incision, with echocardiography confirming LAA exclusion.
Main Results:
- The mean patient age was 73.6 years, with high CHA2DS2VASC (4.7) and HAS-BLED (3.8) scores.
- Successful LAA exclusion (residual sac < 1 cm) was achieved in all patients.
- The mean postoperative length of stay was 6.4 days; one stroke-related death and two cases of pleural effusion occurred.
Conclusions:
- Isolated epicardial LAA clipping is a safe short-term treatment for high-risk AF patients.
- The procedure demonstrates promising results for LAA exclusion in this cohort.
- Long-term efficacy in preventing stroke requires further investigation.
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.
