Pericardial endoscopy-guided left atrial appendage ligation: a pilot study in a canine model.
BACKGROUND
Approaches for closing the left atrial appendage (LAA) have been developed for stroke prevention. However, the prevailing maneuvers require an open-chest surgery, intravascular access, or transseptal puncture. We evaluated the feasibility and safety of pericardial endoscopy-guided LAA ligation in a canine model.


RESULTS
We used a total of 8 canines and computed tomography was performed before the procedures. After a double percutaneous pericardiocentesis, a transurethral rigid endoscope was inserted into the pericardial space. The ENDOLOOP ligature was advanced to the ostium of the LAA by counter pulling the tip of the LAA with forceps. After confirming the positioning guided by transesophageal echocardiography, the ligature was securely tightened. Acute success was evaluated by transesophageal echocardiography and chronic success was evaluated by blood testing, computed tomography, and transesophageal echocardiography. The LAA ligation was safely achieved in all canines without major complications. One month after the ligation, the ligated LAA was replaced by fibrotic tissue, and both the transesophageal echocardiography and computed tomographic images revealed no residual shunt. There was only a localized adhesion of the pericardium, where the original LAA was located, without the need for antibiotic or steroid administration. The postprocedural internal surface of the ligated LAA was smooth by virtue of intimal growth. Blood tests showed a slight elevation of the inflammatory markers, but this normalized spontaneously.


CONCLUSIONS
Pericardial endoscopy-guided LAA ligation could provide an alternative, minimally invasive, and feasible solution for LAA closure that does not require vascular access or a transseptal puncture.
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan. kimura@z7.keio.jp.
Takehiro
T
Kimura
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Seiji
S
Takatsuki
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Shunichiro
S
Miyoshi
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Yoshinori
Y
Katsumata
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Takahiko
T
Nishiyama
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Nobuhiro
N
Nishiyama
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Yoko
Y
Tanimoto
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Yoshiyasu
Y
Aizawa
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Masahiro
M
Jinzaki
From the Departments of Cardiology (T.K., S.T., S.M., Y.K., T.N., N.N., Y.T., Y.A., K.F.) and Radiology (M.J.), Keio University School of Medicine, Tokyo, Japan.
Keiichi
K
Fukuda
D000818:Animals; D020517:Atrial Appendage / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D004285:Dogs; D017548:Echocardiography, Transesophageal; D004724:Endoscopy / Q000009:adverse effects / Q000379:methods*; D005240:Feasibility Studies; D005355:Fibrosis; D008026:Ligation; D023421:Models, Animal; D020519:Pericardiocentesis; D010496:Pericardium / Q000601:surgery*; D010865:Pilot Projects; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D000267:Tissue Adhesions; D014057:Tomography, X-Ray Computed
appendage; endoscopy; ligation