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.