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OBJECTIVE: Atrial fibrillation (AF) is the primary cardiac abnormality associated with ischemic stroke. AF affects 2.7 million people with a stroke rate of 3.5% per year. Most of the emboli in patients with non-valvular AF originate in the left atrial appendage (LAA). Surgical exclusion of the LAA decreases the yearly risk of stroke to 0.65% when combined with a Maze procedure. Traditional over-sewing 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 5/2012 and 12/2015, 24 consecutive patients underwent minimally invasive, echo-guided epicardial clipping. Indications for the procedure were persistent (n=11) or paroxysmal (n=13) AF in patients who could not tolerate full anticoagulation due to a combination of gastrointestinal bleeding (n=6), hemorrhagic stroke (n=5), ischemic stroke (n=5), intramuscular bleeding (n=3), falls (n=2), GU bleed (n=2), subdural hematoma (n=1), Osler-Weber-Randu syndrome (n=1), and a traumatic aortic intramural hematoma (n=1). The clipping was performed through three 5 mm ports in the left 7th intercostal space (n=22) or a 5 cm incision in the 5th intercostal space (n=2). Echocardiography was done to exclude the presence of LAA thrombus and to confirm exclusion of LAA prior to final deployment of the clip.
RESULTS: Mean age was 74.4 years. The mean CHADS2VASC score was 4.6 and the mean HASBLED score was 3.8. Mean post-op length of stay was 5.3 days, and the mode was 1 day. One patient died of stroke related complications 10 days after successful clipping. There were no unexpected adverse events. 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.