Thoracoscopic Left Atrial Appendage Exclusion For Atrial Fibrillation Patients Intolerant To Anti-coagulation
Omar M. Sharaf, Matheus P. Falasa, Todd E. Jones, Anna Y. Khanna, Kun Xiang, Philip George, Vilma Torres, William M. Miles, Thomas M. Beaver.
University of Florida Health, Gainesville, FL, USA.
BACKGROUND: The Left Atrial Appendage Occlusion Study (LAAOS) III trial showed benefit of left atrial appendage (LAA) exclusion with concomitant cardiac surgery; however, most patients remained on anticoagulation. Outcomes associated with isolated epicardial LAA exclusion in atrial fibrillation (AF) patients with a contraindication or intolerance to anticoagulation are not clearly defined, especially in patients with prior stroke. This study evaluated the perioperative safety, medication use, and stroke outcomes for isolated thoracoscopic LAA exclusion for stroke prevention.
METHODS: A single-center retrospective study was performed of adult patients undergoing isolated thoracoscopic LAA exclusion with an epicardial exclusion device without a concomitant surgical procedure. Demographics and short- and long-term outcomes were evaluated with descriptive statistics.
RESULTS: Twenty-six patients met inclusion criteria. The cohort was 65% (n=17) male with a mean age of 75.9±6.8 years and a mean preoperative CHA2DS2-VASc score of 4.3±1.4. Eighteen (69%) patients had non-paroxysmal AF. There were 11 patients with intolerance of anticoagulation due to intracranial hemorrhage (42%), 6 due to gastrointestinal bleeding (23%) and 4 due to genitourinary bleeding (15%). All procedures were performed thoracoscopically with 100% technical success—mean LAA stump length was 5.6±2.4 mm on intraoperative transesophageal echocardiography. Mean hospital length of stay was 4.2±2.5 days. Median follow-up time was 404 (IQR 109, 852) days. During follow-up, one patient with cerebral angiopathy had temporary neurologic deficits at an outside institution with brain imaging showing no evidence of ischemic injury. There were no other thromboembolic events over the 38.9 postoperative patient-years examined. Ninety-six percent of patients were off anticoagulation at last follow-up.
CONCLUSIONS: This retrospective study shows the perioperative safety, technical success, freedom from anticoagulation and stroke outcomes of isolated thoracoscopic LAA exclusion in patients with AF at high risk for thromboembolic disease. Larger prospective studies are needed to confirm the benefit of LAA exclusion in the absence of anticoagulation on a population level.LEGEND: Intraoperative view of epicardially placed left atrial appendage AtriClip (AtriCure, Inc., Mason, OH, USA). LAA, left atrial appendage. 
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