Effectiveness Of Minimally Invasive Left Atrial Appendage Exclusion On Stroke Reduction
PAUL L. DIGIORGI, MD, FACS, Nalani Yeager, BSN, RN, Joseph Deily, PA-C, Randall Buss, MD, FACS, Michael Defrain, MD, FACS, Brian Hummel, MD, FACS, Brian Hummel, MD, FACS.
Lee Health, Fort Myers, FL, USA.
BACKGROUND Thromboembolic (TE) stroke remains a common and morbid complication of atrial fibrillation (AF) despite maximal medical therapy. Open surgical control of the left atrial appendage, in patients with AF, has been associated with a reduction in the incidence of stroke. Minimally invasive surgical approaches to the left atrial appendage provide an attractive option facilitating increased access for patients. We sought to investigate the incidence of TE stroke in our patients that underwent left atrial appendage exclusion and compare those outcomes to expected stroke rates based on CHA₂DS₂-VASc scoring. METHODS All adult cardiac surgical patients who underwent left atrial appendage exclusion at our institution were retrospectively studied. Baseline clinical data including age, type of surgery, approach, and CHA₂DS₂-VASc score were evaluated. The incidence of stroke was calculated at most recent follow up. The observed stroke rate was compared to the expected stroke rate base on CHA₂DS₂-VASc scoring. RESULTS Between September 2011 and June 2017, 241 patients underwent left atrial appendage exclusion as a stand-alone procedure or with other concomitant cardiac surgical procedures. Two hundred and thirty patients (95%) were available for follow up. One hundred and sixty eight patients (73%) of these patients had the procedure performed minimally invasively either by a right minithoracotomy, upper sternotomy, or via a video assisted approach. Median age was 72 (range 43 to 89 years), percent male was 68, median baseline CHA₂DS₂-VASc was 3. One hundred and ten patients (48%) were on oral anticoagulation at the time of follow up. At an average of 21 months follow up, the incidence of embolic stroke was 0.9% versus an expected stroke rate of 5.6% based on their CHA₂DS₂-VASc (p<0.05). CONCLUSIONS Various minimally invasive approaches are feasible for left atrial appendage exclusion. These approaches to left atrial appendage exclusion are associated with a reduction in stroke incidence. Randomized, prospective trials may help clarify the benefits of surgical left atrial appendage exclusion.
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