Standalone Totally Thoracoscopic Left Appendage Clipping: Safe, Simple, Standardized.

Totally thoracoscopic standalone left atrial appendage exclusion has become a valid treatment option for stroke prevention in patients with a contraindication to anticoagulants. As with most other video-assisted surgeries, this procedure requires appropriate patient and port positioning to obtain the most advantageous working angles and standard thoracoscopic skills. Furthermore it is mandatory to have a closure device specifically designed for the appendage to guarantee efficacy and safety and to optimize surgical placement that allows the best clinical outcomes. Here we describe the surgical technique of a unilateral left-sided thoracoscopic approach for surgical exclusion of the appendage on the beating heart.

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

INTRODUCTION: The 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 RESULTS: We 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. CONCLUSION: Thoracoscopic 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.

Epicardial left ventricular lead implantation in cardiac resynchronization therapy patients via a video-assisted thoracoscopic technique: Long-term outcome.

BACKGROUND: Epicardial placement of the left ventricular (LV) lead via a video-assisted thoracoscopic (VAT) approach is an alternative to the standard transvenous technique. HYPOTHESIS: Long-term safety and efficacy of VAT and transvenous LV lead implantation are comparable. To test it, we reviewed our experience and we compared the outcomes of patients who underwent implantation with the two techniques. METHODS: The VAT procedure is performed under general anesthesia, with oro-tracheal intubation and right-sided ventilation, and requires two 5 mm and one 15 mm thoracoscopic ports. After pericardiotomy at the spot of the epicardial target area, pacing measurements are taken and a spiral screw electrode is anchored at the final pacing site. The electrode is then tunneled to the pectoral pocket and connected to the device. RESULTS: 105 patients were referred to our center for epicardial LV lead implantation. After pre-operative assessment, 5 patients were excluded because of concomitant conditions precluding surgery. The remaining 100 underwent the procedure. LV lead implantation was successful in all patients (median pacing threshold 0.8 ± 0.5 V, no phrenic nerve stimulation) and cardiac resynchronization therapy was established in all but one patient. The median procedure time was 75 min. During a median follow-up of 24 months, there were no differences in terms of death, cardiovascular hospitalizations or device-related complications vs the group of 100 patients who had undergone transvenous implantation. Patients of both groups displayed similar improvements in terms of ventricular reverse remodeling and functional status. CONCLUSIONS: Our VAT approach proved safe and effective, and is a viable alternative in the case of failed transvenous LV implantation.

A spectral approach for the quantitative description of cardiac collagen network from nonlinear optical imaging.

The assessment of collagen structure in cardiac pathology, such as atrial fibrillation (AF), is essential for a complete understanding of the disease. This paper introduces a novel methodology for the quantitative description of collagen network properties, based on the combination of nonlinear optical microscopy with a spectral approach of image processing and analysis. Second-harmonic generation (SHG) microscopy was applied to atrial tissue samples from cardiac surgery patients, providing label-free, selective visualization of the collagen structure. The spectral analysis framework, based on 2D-FFT, was applied to the SHG images, yielding a multiparametric description of collagen fiber orientation (angle and anisotropy indexes) and texture scale (dominant wavelength and peak dispersion indexes). The proof-of-concept application of the methodology showed the capability of our approach to detect and quantify differences in the structural properties of the collagen network in AF versus sinus rhythm patients. These results suggest the potential of our approach in the assessment of collagen properties in cardiac pathologies related to a fibrotic structural component.

Early closure of postinfarction ventricular septal defects.

BACKGROUND: According to the guidelines of the American College of Cardiology/American Heart Association early closure of postinfarction septal defects is now a class I indication although it still carries a relevant morbidity and mortality. The operative risk is related both to the critical hemodynamic conditions of the patient and to the technical difficulties posed by the friable tissue of the infarcted area. The most recent techniques involving the use of pericardial patches reinforced by acrylic glue have significantly reduced the hospital mortality. The aim of this study was to discuss the reliability of an aggressive, tissue-sparing surgical approach to this complication. METHODS: We present a consecutive series of 12 patients operated upon between January 1998 and October 2001 within 12 hours of the onset of clinical evidence of postinfarction septal rupture. Repair was achieved with minimal septal debridement and the use of a large pericardial patch reinforced by a biological glue. RESULTS: Three cases of dehiscence required early reoperation with no hospital mortality. CONCLUSIONS: This procedure is technically feasible and allows early aggressive treatment of postinfarction septal rupture with satisfactory results.

Pulmonary valve lipoma presenting as syncope.

We report a case of a pulmonary valve lipoma presenting as syncope in a 28-year-old woman. Surgical excision of the mass was performed in urgency and the patient was discharged uneventfully.