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Left Atrial Appendage Occlusion In Off Pump Coronary Artery Surgery: Pitfalls
Amber Malhotra, Daniel Beckles, Giuseppe Tavilla, Ramachandra Reddy.
Baylor Scott and White Health, Temple, TX, USA.

Surgeons are vary of tackling the LAA (Left Atrial Appendage) on a beating heart. It is now a 1A recommendation to treat atrial fibrillation while tackling other heart valve or coronary lesions. Off pump CABG accounts for less than 15% of the CABGs done in the US. It is not infrequent for a 100% Off pump CABG center like ours to encounter a situation needing appendage exclusion. Options include a cut and sew, staple resection and a clip. We want to showcase one such disaster to that we encountered and managed. METHODS:We describe the case of our patient with CAD and Persistent Atrial Fibrillation undergoing Off pump CABG and Left Atrial Appendage Exclusion. In this case, due to the position of the OM venous graft, the clip was not considered a good option and we decided on the stapler instead. Since, the Left sided deep stay suture and the pericardial stays were pulled up to expose the Appendage the pulmonary veins were tented up and given the moderate MR the OM territory was bulging in the view, hiding the deeper parts of the appendage. The tip of our stapler was not visible as the MR and hemodynamic instability made us hurry through the procedure. The tented Lt upper PV was caught in the stapler and torrential bleeding ensued. RESULTS: Emergency CPB was instituted with great difficulty given the fact that the heart had emptied out. The LUPV was repaired with an autologous pericardial patch. There was no turbulence on the echocardiography and the patient made an uneventful recovery
CONCLUSIONS:If the pitfalls are carefully kept in mind the LAA exclusion is safe and doable making the Off pump CABG a more complete procedure.

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