Author + information
- Received October 3, 2017
- Revision received February 27, 2018
- Accepted March 8, 2018
- Published online May 2, 2018.
- Charlotte van Laar, MDa,
- Niels J. Verberkmoes, MDb,
- Hendrik W. van Es, MD, PhDa,c,
- Thorsten Lewalter, MD, PhDd,
- Gan Dunnington, MDe,
- Stephen Stark, MDf,
- James Longoria, MDf,
- Frederik H. Hofman, MDa,
- Carolyn M. Pierce, RNe,
- Dipak Kotecha, MD, PhDg and
- Bart P. van Putte, MD, PhDa,h,∗ ()
- aDepartment of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
- bDepartment of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
- cDepartment of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- dDepartment of Medicine-Cardiology and Intensive Care, Peter Osypka Heart Center, Clinic Munich-Thalkirchen, Munich, Germany
- eDepartment of Cardiothoracic Surgery, St. Helena Hospital, St. Helena, California
- fDepartment of Cardiothoracic Surgery, Sutter Medical Center, Sacramento, California
- gInstitute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- hDepartment of Cardiothoracic Surgery, AMC Heart Center, Academic Medical Center, Amsterdam, the Netherlands
- ↵∗Address for correspondence
: Dr. Bart P. van Putte, Department of Cardiothoracic Surgery, St. Antonius Hospital, P.O. Box 2500, 3430 EM, Nieuwegein, the Netherlands.
Objectives This study sought to document the closure rate, safety, and stroke rate after thoracoscopic left atrial appendage (LAA) clipping.
Background The LAA is the main source of stroke in patients with atrial fibrillation, and thoracoscopic clipping may provide a durable and safe closure technique.
Methods The investigators studied consecutive patients undergoing clipping as part of a thoracoscopic maze procedure in 4 referral centers (the Netherlands and the United States) from 2012 to 2016. Completeness of LAA closure was assessed by either computed tomography (n = 100) or transesophageal echocardiography (n = 122). The primary outcome was complete LAA closure (absence of residual LAA flow and pouch <10 mm). The secondary outcomes were 30-day complications; the composite of ischemic stroke, hemorrhagic stroke, or transient ischemic attack; and all-cause mortality.
Results A total of 222 patients were included, with a mean age of 66 ± 9 years, and 68.5% were male. The mean CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65 to 74 years, sex category [female]) score was 2.3 ± 1.0. Complete LAA closure was achieved in 95.0% of patients. There were no intraoperative or clip-related complications, and the overall 30-day freedom from any complication rate was 96.4%. The freedom from cerebrovascular events after surgery was 99.1% after median follow-up of 20 months (interquartile range: 14 to 25 months; 369 patient-years of follow-up), and overall survival was 98.6%. The observed rate of cerebrovascular events after LAA clipping was low (0.5 per 100 patient-years).
Conclusions LAA clipping during thoracoscopic ablation is a feasible and safe technique for closure of the LAA in patients with atrial fibrillation. The lower than expected rate of cerebrovascular events after deployment was likely multifactorial, including not only LAA closure, but also the effect of oral anticoagulation and rhythm control.
Dr. van Laar is funded by an unrestricted research grant from AtriCure. Dr. Verberkmoes is a speaker for AtriCure, Medtronic, and Abbott; and is a proctor for AtriCure. Dr. van Putte is a proctor for AtriCure. Dr. Dunnington is a proctor and consultant for AtriCure; and has received honoraria from AtriCure. Ms. Pierce is a consultant for AtriCure. Dr. Kotecha has received research grants from Menarini; has received speaker fees from AtriCure; and has received professional development support from Daiichi Sankyo.
Drs. Kotecha and van Putte contributed equally to this work and are joint senior authors.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received October 3, 2017.
- Revision received February 27, 2018.
- Accepted March 8, 2018.
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