Thoracoscopic extracardiac obliteration of the left atrial appendage for stroke risk reduction in atrial fibrillation.
OBJECTIVE
We evaluated left atrial appendage obliteration in high-risk patients with atrial fibrillation (AF).


BACKGROUND
Left atrial appendage thrombosis and embolization is the principal mechanism of stroke in AF. Anticoagulation is underutilized and often contraindicated.


METHODS
Thoracoscopic Left Appendage, Total Obliteration, No cardiac Invasion (LAPTONI) was undertaken with a loop snare in eight patients and a stapler in seven patients, median age 71 years, with clinical risk factors for stroke and with an absolute contraindication to or failure of prior thrombosis prevention with warfarin. Eleven patients had a history of prior thromboembolism. One patient took sustained warfarin during follow-up.


RESULTS
The LAPTONI procedure was completed in 14 of 15 patients, and 1 patient required urgent conversion to open thoracotomy because of bleeding. Patients have been followed up for 8 to 60 months, mean 42 +/- 14 months. One fatal stroke occurred 55 months after surgery, and one non-disabling stroke three months after surgery. Two other deaths occurred, one after coronary bypass surgery and the other from hepatic failure. The subgroup of 11 patients with prior thromboembolism had an annualized rate of stroke of 5.2% per year (95% confidence interval [CI] 1.3 to 21) after LAPTONI, which compares to a rate of 13% per year (95% CI 9.0 to 19) for similar aspirin-treated patients from the Stroke Prevention in Atrial Fibrillation trials (p = 0.15).


CONCLUSIONS
The LAPTONI procedure appears technically feasible without immediate disabling neurologic morbidity or mortality, and it demonstrates low post-operative event rates and a statistical trend toward thromboembolic risk reduction in high-risk AF patients.
Blackshear
Joseph L
JL
Mayo Clinic Jacksonville, Jacksonville, Florida 32224, USA. blackshear.joseph@mayo.edu
Johnson
W Dudley
WD
Odell
John A
JA
Baker
Vickie S
VS
Howard
Mary
M
Pearce
Lesly
L
Stone
Christopher
C
Packer
Douglas L
DL
Schaff
Hartzell V
HV
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D020517:Atrial Appendage / Q000000981:diagnostic imaging / Q000601:surgery*; D001281:Atrial Fibrillation / Q000150:complications*; D002561:Cerebrovascular Disorders / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D018572:Disease-Free Survival; D017548:Echocardiography, Transesophageal; D005260:Female; D005431:Florida; D006325:Heart Atria / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D012307:Risk Factors; D013906:Thoracoscopy / Q000379:methods*; D013923:Thromboembolism / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D014922:Wisconsin