Standalone Thoracoscopic Epicardial Left Atrial Appendage Exclusion Without Any Antithrombotic Therapy in a Multidisciplinary Practice: Long Term Clinical Outcomes

Introduction According to 2024 ESC AF Guidelines with Doacs having similar bleeding risk of aspirin the role of endovascular left atrial appendage occlusion with the mandatory post procedure antithrombotic therapy for stroke prevention is defined “unclear”. Thoracoscopic epicardial closure does not require any post procedure antiplatelet therapy due to the extravascular position of the device. Objective To investigate safety efficacy of standalone thoracoscopic epicardial left atrial appendage exclusion without any antiplatelet therapy for stroke and bleeding prevention in patients with atrial fibrillation and contraindication/poor tolerance to anticoagulants. Methods Between 2017–2024, 342 patients with atrial fibrillation and contraindication/poor tolerance to anticoagulants (male 68%; mean age 78±7.7, CHA2DS2VA4.2±1.3, HASBLED3.1±1.6) underwent multidisciplinary evaluation for standalone totally thoracoscopic appendage exclusion. No anticoagulant/antiplatelet therapy was prescribed post procedure and for entire follow up. Follow up was at 3,6,12 months and yearly thereafter. EQ5D 5L questionnaire was used for quality of life evaluation at pre procedure and art 12 months. Results 337 patients underwent epicardial closure, mean follow up 36.3±18.7. Stroke, cumulative stroke/TIA/periferal embolism o bleeding were 0.45 (95%CI:0.12–1.14) (RRR93%), 0.78 (0.32–1.62) (RRR92%) e 0.44 (0.12–1.15) (RRR92%), respectively. EQ5D5L score increate from median 50(IQR 40–60) to 72(IQR 70–78) (p‹0.001) at 12 months. Conclusion Standalone epicardial appendage occlusion without any antithrombotic therapy is safe and effective for cardioembolic and bleeding prevention in patients with atrial fibrillation and contraindication/poor tolerance to anticoagulants and is associated with improved quality of life.