title: Totally Endoscopic Robotic Left Atrial Appendage Closure Demonstrates High Success Rate.
abstract: OBJECTIVE
  In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates.
  
  
  METHODS
  Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4-0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm.
  
  
  RESULTS
  Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow.
  
  
  CONCLUSIONS
  We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.
authors.affiliation: From the Departments of *Cardiothoracic Surgery, †Cardiology, and ‡Anesthesia, New York University School of Medicine, New York, NY USA.
authors.forename: Alison F
authors.initials: AF
authors.lastname: Ward
authors.forename: Robert M
authors.initials: RM
authors.lastname: Applebaum
authors.forename: Nana
authors.initials: N
authors.lastname: Toyoda
authors.forename: Ans
authors.initials: A
authors.lastname: Fakiha
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Neuburger
authors.forename: Jennie
authors.initials: J
authors.lastname: Ngai
authors.forename: Robert G
authors.initials: RG
authors.lastname: Nampiaparampil
authors.forename: David W
authors.initials: DW
authors.lastname: Yaffee
authors.forename: Didier F
authors.initials: DF
authors.lastname: Loulmet
authors.forename: Eugene A
authors.initials: EA
authors.lastname: Grossi
mesh_terms: D000368:Aged; D020517:Atrial Appendage / Q000601:surgery*; D001281:Atrial Fibrillation / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000295:instrumentation* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*; D016896:Treatment Outcome; D058106:Wound Closure Techniques / Q000295:instrumentation