Left atrial appendage exclusion using a stapler with thoracoscopic ablation of atrial fibrillation

Highlights. Stroke prevention in patients with atrial fibrillation is extremely important and difficult. Lifelong anticoagulant therapy is not always an effective way of preventing thrombosis in the left atrial appendage in this group of patients. In this regard, one of the most urgent problems of modern surgical arrhythmology and cardiac surgery is the search for new open and minimally invasive surgical methods of excluding the left atrial appendage from the blood flow. Aim. To investigate the safety and efficacy of using the left atrial appendage stapler for video-guided thoracoscopic ablation (TSA) of non-valvular atrial fibrillation (AF). Methods. The retrospective, single-center study included 100 patients with non-valvular AF who underwent video-guided thoracoscopic ablation of AF with single-stage left atrial appendage exclusion using an Endo GIA stapler (Medtronic, Minneapolis, Minnesota, USA). Results. The mean age of the patients was 56,2±8,8 years, the majority of the patients (73 patients, 73%) were male. Patients with persistent 50 (50%) AF and longstanding AF 50 (50%) were included in the study. The duration of atrial fibrillation was 4 (1,7–7) years. The median CHA2DS2-VASc and HAS-BLED scores were 2 (1–1,5) and 1 (0-1), respectively. The mean anticoagulation therapy-to-ablation time was 4,2±1,9 years. Thirty-eight (38%) patients were prescribed warfarin preoperatively. The completeness of left atrial appendage (LAA) exclusion was confirmed by intraoperative transesophageal echocardiography. The average length of the staple lines was 48 (35–75). A single left atrial appendage exclusion was performed using a 60 mm staples. In 12 (12%) patients, stapler exclusions were performed using two 45 mm staples due to insufficient staple length. None of the patients had ruptures, punctures along the staple lines or rupture of the surrounding epicardial tissue. Anticoagulant therapy was discontinued 6 months after TSA in 70 (70%) patients with sustained sinus rhythm observed on 24-h Holter Monitoring, satisfactory CHA2DS2-VASc scores and after confirmation of absence of left atrial thrombus by transesophageal echocardiography and contrast-enhanced MSCT. No strokes were reported within 1,2±0,7 years after discontinuing anticoagulation therapy. Conclusion. Exclusion of LAA using a stapler for TSA is a highly effective and safe technique for patients with non-valvular atrial fibrillation compared to alternative methods of excluding the LAA from the systemic blood flow.