Thoracoscopic Left Atrial Appendectomy Can Be An Alternative To Anticoagulation Therapy In Atrial Fibrillation Patients
Takafumi Inoue1, Toshiya Ohtsuka2, Yoshihiro Suematsu1.
1Tsukuba Memorial Hospital, Tsukuba, Japan, 2Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
OBJECTIVE: Although anticoagulation therapy is the gold standard of prophylaxis for cardiogenic thromboembolism in patients with atrial fibrillation (AF), thromboembolic events sometimes occur even when administering anticoagulants. Thoracoscopic left atrial appendectomy (TLAA) has been suggested as a new approach to prevent cardiogenic thromboembolism in patients with AF, and we examined the effectiveness and safety of this surgical method.
METHODS: Sixty consecutive patients (mean age, 70±7 years, 46 males, mean CHA2DS2-VASc score, 2.9±1.6 points) with a high risk of thromboembolism and/or bleeding were selected for TLAA. Fifty-seven of these patients had been treated with anticoagulants preoperatively. (Three patients had stopped anticoagulation therapy due to the negative side effect of bleeding.) Seventeen patients had suffered a stroke/TIA (transient ischemic attack) and two patients had a history of thromboembolism before undergoing surgery. In addition, cerebral hemorrhage had also developed in five patients preoperatively. The left atrial appendage was excised with an endoscopic linear cutter thoracoscopically in the right lateral recumbent position with differential lung ventilation. Four endoscopic ports (for the endoscope, endoscopic cutter and forceps) were normally made in the left thorax, while monitoring the procedures by transesophageal echocardiography.
RESULTS: TLAA (mean operation time 37±9 min) resulted in no mortality and no major complications. All of the patients were discharged while able to maintain their same activities of daily living in postoperative period of 4.3±1.8 days. Anticoagulants were stopped postoperatively and no cardiogenic thromboembolism events occurred, and the mean follow-up duration was 16±7 months. The rates of freedom from cardiogenic thromboembolism were significantly different between the preoperative and postoperative periods in the same patient groups (preoperatively with anticoagulants) (p < 0.01 log-rank test, Figure).
CONCLUSIONS: TLAA is considered to be an effective approach for the prophylaxis of cardiogenic thromboembolism, and its safety is also deemed to be adequate. Especially for patients who are refractory to (or contraindicated for) anticoagulants, this operation would be an optimal therapeutic option.
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