Thoracoscopic Left Atrial Appendage Epicardial Clipping For Stroke Prevention In Patients With Atrial Fibrillation - Long Term Follow-up
Anna Witkowska1, Grzegorz Suwalski2, Maciej Bartczak1, Radosław Smoczyński1, Dominik Drobinski1, Mariusz Kowalewski1, Jakub Staromlynski1, Dariusz Kosior1, Piotr Suwalski1.
1Central Clinical Hospital of the Ministry of Interior in Warsaw, Warsaw, Poland, 2Militari Institute of Medicin, Warsaw, Poland.
BACKGROUND: Atrial fibrillation is associated with significantly elevated risk of stroke. Left atrial appendage (LAA) is the main source of thrombotic material. Oral anticoagulation remains the standard of care, however, is associated with significant complications. Here we present long-term results of the epicardial clipping system for the totally thoracoscopic LAA exclusion for stroke prevention in high-risk patients with atrial fibrillation.
METHODS: 80 patients (33 female) in the mean age of 67(+/-10) years with persistent atrial fibrillation underwent totally thoracoscopic LAA exclusion. In 26(32%) of patients concomitant totally thoracoscopic ablation was performed. Prior to operation 22(27%) patients underwent stroke, 5 (6%) had recurrent thrombus in left atrial appendage, 9(11%) were disqualified form percutaneous procedure, 21% had a gastrointestinal bleeding history, and 9(11%) intracranial bleeding. The mean CHA2DS2VASC Score was 4(+/-2) and the mean HAS_BLED Score was from 2(+/-1). All patients had transesophageal echocardiography to rule out thrombus and guide the deployment of the clip at the base of left atrium appendage. In 50 (63%) patients transesophageal echocardiography or computed tomography was performed after 6 months of implantation to assess its effectiveness.
RESULTS: There was no mortality. There were no conversions to sternotomy, one patient required thoracoscopic chest revision due to elevated drainage without further complications, one patient underwent hemorrhagic stroke with mild symptoms. Mean hospitalization time was 6(+/-3) days. In a mean follow-up of 25(+/-10) months, there were no strokes, nor TIA. One patient had gastrointestinal bleeding without further morbidity. There were 4(5%) deaths during follow-up not related to the clip placement. 47(59%) patientes were off oral anticoagulation. Stable clip position without stump bigger than 10 mm or leakage was confirmed in 49 out of 50 patients (98%) who reached 6 months follow-up and were willing to undergo echocardiography or computed tomography examination.
CONCLUSIONS: The totally thoracoscopic LAA exclusion with an epicardial clipping system shows high efficacy in LAA closure and offers very good long-term stroke prevention in high-risk patients with a low rate of complications.
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