Surgical techniques for left atrial appendage exclusion

Abstract

The increasing prevalence of atrial fibrillation with the aging population and its associated major morbidity and mortality due to thromboembolic stroke have resulted in intensive research on stroke prevention or stroke risk reduction strategies. Several surgical techniques for left atrial appendage (LAA) occlusion have evolved over the past decades. Surgeons have been using different techniques leading to highly variable and, in particular, poor data on outcomes. LAA closure is performed either as a concomitant procedure during open-heart surgery or as a stand-alone surgical procedure as part of minimally invasive (mini-thoracotomy or thoracoscopy) arrhythmia surgery. Data on the safety and feasibility of surgical LAA occlusion are derived mainly from nonrandomized case series, observational and cohort studies, or registries with mostly inconclusive and conflicting results. Increased awareness of the high failure rates in attaining complete LAA occlusion, thus avoiding poor surgical techniques (e. g., simple suture ligation, endocardial suturing etc.), and the availability of newer devices (e. g., AtriClip device) have recently led to improved surgical results in the literature. If further validated in large-scale studies, these recent promising developments in the field of surgical LAA treatment seem to offer alternatives for patients ineligible for oral anticoagulation therapy with vitamin K antagonists or newer non-vitamin-K-dependent oral anticoagulants.

2023 KASNet Guidelines on Atrial Fibrillation Surgery

“…Various surgical techniques that eliminate the LAA by cavity obliteration have been introduced and can be divided into epicardial versus endocardial- and non-device-enabled versus device-enabled techniques [ 130 ].…”

The Efficacy and Safety of the WATCHMAN Device in LAA Occlusion in Patients with Non-Valvular Atrial Fibrillation Contraindicated to Oral Anticoagulation: A Focused Review

“…Until recently, various surgical treatment strategies or percutaneous techniques with different types of devices for LAAC are available. 24,25) Surgical LAAC is divided into two categories: exclusion or excision. 26,27) Epicardial surface exclusion includes running or mattress sutures with or without felt pledgets, purse-string sutures from the epicardial surface, or running sutures or purse-string sutures from the endocardial surface, and single ligation techniques.…”

“…It was an interesting observation from the AtriClip device, whereby the epicardial LAA clip occlusion leads to the electrical isolation of the LAA which offers more advantage of the device not only offering stroke prevention but also reduce the chance of AF to recur again. The following are the advantages of the AtriClip device enabled epicardial LAAC: 24) after implantation and complete closure of the LAA using AtriClip, it is not necessary to continue short-term or long-term OACs or antiplatelet treatment, therefore for those patients contraindicated to OACs can acquire benefit from this device. Periprocedural safety events, peridevice flow, and operator-dependent learning curve are in favor of surgical LAAC using clipping when compared to interventional approaches, and the AtriClip device implantation is cost-effective than interventional implantation of devices.…”

Utilization of WATCHMAN FLX for surgically incomplete left atrial appendage occlusion: a multicentre case series

“… 3 These approaches include but are not limited to suture exclusion or excision, suture/snares loops, and clipping. 4 To this day, certain surgical approaches have shown relatively unfavourable results with higher failure and complication rates compared with the newer percutaneous endocardial approaches as seen with the WATCHMAN FLX implant. 5–7 Often times, patients undergoing surgical LAA closure are left with incomplete occlusion, leaving behind residual lobes that continue to allow thrombi formation.…”