title: Thoracoscopic extracardiac obliteration of the left atrial appendage for stroke risk reduction in atrial fibrillation.
abstract: 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.
authors.affiliation: Mayo Clinic Jacksonville, Jacksonville, Florida 32224, USA. blackshear.joseph@mayo.edu
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Blackshear
authors.forename: W Dudley
authors.initials: WD
authors.lastname: Johnson
authors.forename: John A
authors.initials: JA
authors.lastname: Odell
authors.forename: Vickie S
authors.initials: VS
authors.lastname: Baker
authors.forename: Mary
authors.initials: M
authors.lastname: Howard
authors.forename: Lesly
authors.initials: L
authors.lastname: Pearce
authors.forename: Christopher
authors.initials: C
authors.lastname: Stone
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Packer
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
mesh_terms: 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