Sage Journals: Discover world-class research

Abstract

Objective

In nonvalvular atrial fibrillation (AF) patients at high bleeding risk, oral anticoagulants (OAC) may be contraindicated, and percutaneous left atrial appendage (LAA) closure has been advocated. However, following percutaneous procedure, either OAC or dual antiplatelet treatment is required. In this study, we present our experience in treating nonvalvular AF patients at high bleeding risk with thoracoscopic LAA closure with no subsequent antithrombotic therapy.

Methods

From April 2019 to January 2020, 20 consecutive AF patients, mean age 75.1 years, 16 (80%) males, underwent thoracoscopic LAA closure as a stand-alone procedure, using an epicardial clip device. OAC and antiplatelet therapy were contraindicated. Mean CHA₂DS₂-VASc score was 3.61, and the mean HAS-BLED score was 4.42. Successful LAA closure was assessed by transesophageal echocardiography. Primary endpoints were complete LAA closure (no residual LAA flow), operative complications, and all-cause mortality; secondary endpoints were 30-day and 6-month complications (death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, any bleeding). Mean follow-up was 6 ± 4 months.

Results

Complete LAA closure was achieved in all patients. No operative clip-related complications or deaths occurred. At follow-up, freedom from postoperative complications was 95% and from any cerebrovascular events was 100%. Overall survival rate was 100%.

Conclusions

In nonvalvular AF patients at high bleeding risk (HAS-BLED score >3), thoracoscopic LAA closure appears to be a valid alternative to percutaneous techniques not requiring dual antiplatelet or OAC treatment. Apparently, external LAA clipping minimizes the risk of thromboembolic events as compared with percutaneous procedures.

Keywords

thoracoscopy left atrial appendage atrial fibrillation high bleeding risk AtriClip

Get full access to this article

View all access options for this article.

References

Kirchhof

Benussi

Kotecha

et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37: 2893–2962.doi:10.1093/eurheartj/ehw210

http://www.ncbi.nlm.nih.gov/pubmed/27567408

Lane

DA.

Skjøth

Lip

GYH

et al. Temporal trends in incidence, prevalence, and mortality of atrial fibrillation in primary care. J Am Heart Assoc 2017; 6: e005155.doi:10.1161/JAHA.116.005155

http://www.ncbi.nlm.nih.gov/pubmed/28455344

Schnabel

RB.

Yin

Gona

et al. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. Lancet 2015; 386: 154–162.doi:10.1016/S0140-6736(14)61774-8

http://www.ncbi.nlm.nih.gov/pubmed/25960110

Beigel

Wunderlich

NC.

et al. The left atrial appendage: anatomy, function, and noninvasive evaluation. JACC Cardiovasc Imaging 2014; 7: 1251–1265.doi:10.1016/j.jcmg.2014.08.009

http://www.ncbi.nlm.nih.gov/pubmed/25496544

January

CT.

Wann

LS.

Calkins

et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation 2019; 140: e125–e151.doi:10.1161/CIR.0000000000000665

http://www.ncbi.nlm.nih.gov/pubmed/30686041

Lip

GYH.

Frison

Halperin

et al. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol 2011; 57: 173–180.doi:10.1016/j.jacc.2010.09.024

http://www.ncbi.nlm.nih.gov/pubmed/21111555

Squiers

JJ.

Edgerton

. Surgical closure of the left atrial appendage: the past, the present, the future. J Atr Fibrillation 2018; 10: 1642.doi:10.4022/jafib.1642

http://www.ncbi.nlm.nih.gov/pubmed/29988257

Kanderian

AS.

Gillinov

AM.

Pettersson

et al. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol 2008; 52: 924–929.doi:10.1016/j.jacc.2008.03.067

http://www.ncbi.nlm.nih.gov/pubmed/18772063

Reddy

VY.

Doshi

SK.

Sievert

et al. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) Trial. Circulation 2013; 127: 720–729.doi:10.1161/CIRCULATIONAHA.112.114389

http://www.ncbi.nlm.nih.gov/pubmed/23325525

10.

Holmes

DR.

Doshi

SK.

Kar

et al. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis. J Am Coll Cardiol 2015; 65: 2614–2623.doi:10.1016/j.jacc.2015.04.025

http://www.ncbi.nlm.nih.gov/pubmed/26088300

11.

Reddy

. Left atrial appendage closure devices: a reasonable therapeutic alternative. Heart Rhythm 2018; 15: 302–305.doi:10.1016/j.hrthm.2017.10.006

http://www.ncbi.nlm.nih.gov/pubmed/29030234

12.

Pillarisetti

Reddy

YM.

Gunda

et al. Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: understanding the differences in the location and type of leaks and their clinical implications. Heart Rhythm 2015; 12: 1501–1507.doi:10.1016/j.hrthm.2015.03.020

http://www.ncbi.nlm.nih.gov/pubmed/25778430

13.

Viles-Gonzalez

JF.

Kar

Douglas

et al. The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol 2012; 59: 923–929.doi:10.1016/j.jacc.2011.11.028

http://www.ncbi.nlm.nih.gov/pubmed/22381428

14.

Reddy

VY.

Doshi

SK.

Kar

et al. 5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF Trials. J Am Coll Cardiol 2017; 70: 2964–2975.doi:10.1016/j.jacc.2017.10.021

29103847

15.

Caliskan

Sahin

Yilmaz

et al. Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery. Europace 2017; 104: 127–132.

16.

Massimiano

PS.

Shuman

et al. New approach to exclude the left atrial appendage during minimally invasive cryothermic surgical ablation. Innovations 2015; 10: 323–327.doi:10.1097/imi.0000000000000179

http://www.ncbi.nlm.nih.gov/pubmed/26523825

17.

Mokracek

Kurfirst

Bulava

et al. Thoracoscopic occlusion of the left atrial appendage. Innovations 2015; 10: 179–182.doi:10.1097/imi.0000000000000169

http://www.ncbi.nlm.nih.gov/pubmed/26181584

18.

Ramlawi

Bedeir

Edgerton

. Totally thoracoscopic closure of the left atrial appendage. Ann Thorac Surg 2019; 107: e71–e73.doi:10.1016/j.athoracsur.2018.07.046

http://www.ncbi.nlm.nih.gov/pubmed/30240767

19.

Ellis

CR.

Aznaurov

SG.

Patel

et al. Angiographic efficacy of the Atriclip left atrial appendage exclusion device placed by minimally invasive thoracoscopic approach. JACC Clin Electrophysiol 2017; 3: 1356–1365.doi:10.1016/j.jacep.2017.03.008

http://www.ncbi.nlm.nih.gov/pubmed/29759664

20.

van Laar

Verberkmoes

NJ.

van Es

et al. Thoracoscopic left atrial appendage clipping: a multicenter cohort analysis. JACC Clin Electrophysiol 2018; 4: 893–901.doi:10.1016/j.jacep.2018.03.009

http://www.ncbi.nlm.nih.gov/pubmed/30025689

21.

Lip

GYH.

Halperin

. Improving stroke risk stratification in atrial fibrillation. Am J Med 2010; 123: 484–488.doi:10.1016/j.amjmed.2009.12.013

http://www.ncbi.nlm.nih.gov/pubmed/20569748

22.

January

CT.

Wann

LS.

Alpert

et al. AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 2014: e1–e76.

23.

Cairns

. ACP journal club. CHA2DS2-VASc had better discrimination than CHADS2 for predicting risk for thromboembolism in atrial fibrillation. Ann Intern Med 2011; 154: 5–13.doi:10.7326/0003-4819-154-10-201105170-02013

http://www.ncbi.nlm.nih.gov/pubmed/21576531

24.

Pisters

Lane

DA.

Nieuwlaat

et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138: 1093–1100.doi:10.1378/chest.10-0134

http://www.ncbi.nlm.nih.gov/pubmed/20299623

25.

Salzberg

SP.

Gillinov

AM.

Anyanwu

et al. Surgical left atrial appendage occlusion: evaluation of a novel device with magnetic resonance imaging. Eur J Cardiothorac Surg 2008; 34: 766–770.doi:10.1016/j.ejcts.2008.05.058

http://www.ncbi.nlm.nih.gov/pubmed/18693117

26.

Vos

LM.

Kotecha

Geuzebroek

GSC

et al. Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis. Europace 2018; 20: 1790–1797.doi:10.1093/europace/eux385

http://www.ncbi.nlm.nih.gov/pubmed/29361045

27.

Jones

WJ.

Williams

LS.

Meschia

. Validating the Questionnaire for Verifying Stroke-Free Status (QVSFS) by neurological history and examination. Stroke 2001; 32: 2232–2236.doi:10.1161/hs1001.096191

http://www.ncbi.nlm.nih.gov/pubmed/11588306

28.

Badhwar

Rankin

JS.

Damiano

et al. The Society of Thoracic Surgeons 2017 clinical practice guidelines for the surgical treatment of atrial fibrillation. Ann Thorac Surg 2017; 103: 329–341.doi:10.1016/j.athoracsur.2016.10.076

http://www.ncbi.nlm.nih.gov/pubmed/28007240

29.

Akca

Verberkmoes

NJ.

Verstraeten

et al. Is there an alternative treatment for patients intolerant to antiplatelet therapy if percutaneous left atrial appendage closure is considered? Neth Heart J 2017; 25: 510–515.doi:10.1007/s12471-017-0987-y

http://www.ncbi.nlm.nih.gov/pubmed/28429136

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.36 MB

0.00 MB

Stand-Alone Thoracoscopic Left Atrial Appendage Closure in Nonvalvular Atrial Fibrillation Patients at High Bleeding Risk

Abstract

Objective

Methods

Results

Conclusions

Keywords

Get full access to this article

References

Supplementary Material