Anterior Pathway For Epicardial Left Atrial Appendage Clip Occlusion During Minimally-invasive Cardiac Surgery: A Single-center Case Series
Maximilian Vondran, Katharina Wehrmann, Bernd Westphal, Lutz Hilker, David Hirschl, Hauke Paarmann, Matthias Heringlake, Alexander Kaminski.
Klinikum Karlsburg, Heart and Diabetes Center Mecklenburg-Western Pomerania, Karlsburg, Germany.
BACKGROUND: Epicardial left atrial appendage occlusion (LAAO) by placing a clip through the transverse sinus can be technically challenging during minimally-invasive cardiac surgery via a right anterolateral minithoracotomy (MICS). This case series aimed to test the feasibility of the new endoscopic anterior pathway for epicardial LAAO during MICS. METHODS: All patients with MICS with concomitant LAAO using an epicardial clip device (AtriClip Pro 1, AtriCure, Dayton, OH, USA) between January 2022 and November 2022 were included. The preoperative, intraoperative, and postoperative data were retrospectively collected and analyzed. RESULTS: Thirteen patients (median age 64 (first quartile, third quartile; 51, 65)) were included in this case series. Seven patients were male. Preoperative left ventricular function was 55 (50, 60) %, and EuroScore II was 2.6 (1.8, 3.4) %.All patients received their clip beating heart on cardiopulmonary bypass. Ten patients received a 45 mm and 3 a 40 mm LAAO clip. Mitral valve reconstruction was performed in 7 patients, with 3 receiving additional cryoablation. Mitral valve replacement with biological prosthesis was performed in 2 patients, with one receiving additional tricuspid valve reconstruction. One patient each received tricuspid valve replacement with a biological prosthesis, right atrial thrombus removal, tricuspid valve reconstruction with cryoablation, and atrial septal defect (ASD) occluder removal with ASD patch closure as reoperation. In two patients, the primary diagnosis was endocarditis. The application of all clips was sufficient under transesophageal echocardiographic control. There was no conversion to sternotomy, no reoperation for bleeding, no postoperative neurological deficit, no myocardial infarction, and no in-hospital death. The length of hospital stay was 9 (8, 16) days.CONCLUSIONS:This suggests that the anterior endoscopic pathway may be a safe and effective technique for epicardial LAAO during MICS via a right anterolateral mini-thoracotomy. 
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