The value of standalone thoracoscopic epicardial left appendage exclusion and isolation in a multidisciplinary practice: long term clinical outcomes and quality of life

Background Epicardial left appendage exclusion,unlike endovascular procedures,does not mandate antithrombotic therapy for stroke prevention while providing concomitant electrical isolation. In 2024 ESC AF guidelines with direct oral anticoagulants having same bleeding risk of aspirine the role of appendage occlusion for stroke prevention is defined unclear regardless of the approach used on the assumption that post procedure antiplatelet therapy is mandatory. Data on epicardial closure and isolation might contribute to clarify on this topic and further document the benefit of a left appendage electrical isolating procedure. Purpose to evaluate safety and efficacy of standalone thoracoscopic appendage exclusion-isolation as destination therapy for stroke, bleeding prevention and electrical isolation in patients with poor tolerance to anticoagulants or with documented electrical triggers in the appendage. Methods Between 2016-2025, four hundred and twenty patients with AF and poor tolerance to anticoagulants or focal atrial tachycardia firing in the appendage (male 69%; mean age 78,CHA2DS2VA4.2±1.7, HASBLED3.3±1.3) underwent multidisciplinary evaluation for standalone totally thoracoscopic left atrial appendage exclusion-isolation. No antithrombotic therapy was prescribed after the procedure unless appendage exclusion indicated for left atrial thrombosis or major stroke while on anticoagulants. Follow up was at 10 days, 3,6,12 months and yearly thereafter with additional electronic health database interrogation. EQ-5D-5L was used to assess quality of life pre procedure and at 12 months Results 385 patients underwent totally thoracoscopic left atrial appendage exclusion-isolation, 35 continued pharmacological therapy. In the thoracoscopy group at follow up 90% of patients received no antithrombotic therapy, 5.9% were on anticoagulants, and 2.1% on single antiplatelet therapy for significnt carotid stenosis. In the treated groups overall incidence of stroke was 0.43(95%CI:0.12-1.14)(RRR93%),overall composite outcomes stroke/TIA/sistemic embolism incidence was 0.79(0.32-1.62)(RRR92%),overall bleeding events was 0.40(0.12-1.15)(RRR93%). Overall survival in treated vs untreated was 99%(95%CI98-100%) vs 85%(CI:71%-98%) at 1 year and 90%( 95%CI:85%-95%) vs 47% ( 95%CI:27-68%) at 4 years ( p<0.0001). Cause specific survival was 100% vs 90% at 1 year and 98%vs 82 at 4years (p<0.001) EQ5D5L scores increased from median 50(IQR 40-60) to 72(IQR 70-78)(p<0.001) over a 12 months. Conclusion Thoracoscopic left atrial appendage occlusion not requiring antiplatelet therapy is safe, effective and appear a patient-tailorable therapeutic option with improved survival and quality of life.