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

Abstract

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.