Epicardial standalone left atrial appendage clipping for prevention of ischemic stroke in patients with atrial fibrillation contraindicated for oral anticaogulation

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Nonvalvular atrial fibrillation with absolute contraindications to oral anticoagulation (n=45). Intervention: Epicardial left atrial appendage clipping (AtriClip PRO2). Primary outcome: Ischemic stroke or hemorrhagic complications.

Q: What does this research mean for the field?

Thoracoscopic epicardial left atrial appendage clipping provides safe and complete appendage occlusion without ischemic strokes or bleeding complications in atrial fibrillation patients contraindicated for anticoagulation and antiplatelet therapy. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Stefano Branzoli; Massimiliano Marini; Fabrizio Guarracini; Carlo Pederzolli; Claudio Pomarolli; Giovanni D’Onghia; Maurizio Centonze; Mauro Fantinel; Francesco Corsini; Roberto Bonmassari; Angelo Graffigna; Mark La Meir

doi:10.1111/jce.14599

June 4, 2020Journal of Cardiovascular Electrophysiology

Epicardial standalone left atrial appendage clipping for prevention of ischemic stroke in patients with atrial fibrillation contraindicated for oral anticaogulation

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Key result

Epicardial LAA clipping shows 0 strokes or hemorrhagic complications in OAC-ineligible AF.

n=45

Why the study?

The optimal stroke prevention strategy in patients with AF at high thromboembolic risk who have contraindications to oral anticoagulation remains undefined.

Does standalone totally thoracoscopic epicardial LAA clipping prevent ischemic stroke and hemorrhagic complications in patients with NVAF who are absolutely contraindicated for oral anticoagulation?

Study Design

Type

Observational (n=45)

Structured PICO

Does standalone totally thoracoscopic epicardial LAA clipping prevent ischemic stroke and hemorrhagic complications in patients with NVAF who are absolutely contraindicated for oral anticoagulation?

P

Population

45 patients (mean age 73.1 years) with nonvalvular atrial fibrillation and absolute contraindications to oral anticoagulation underwent epicardial LAA clipping and were followed for a mean of 16.4 months.

E

Exposure

Standalone totally thoracoscopic epicardial left atrial appendage (LAA) clipping (using AtriClip PRO2 device) guided by preoperative computed tomography and intraoperative transesophageal echocardiography.

O

Outcome

Ischemic stroke, hemorrhagic complications, and complete LAA occlusion at follow-uphard clinical

Thoracoscopic epicardial LAA clipping is a safe and effective alternative for stroke prevention in NVAF patients with absolute contraindications to oral anticoagulation and antiplatelet therapy.

Implication

May support epicardial LAA clipping in anticoagulation-ineligible AF; hypothesis-generating and requires randomized confirmation.

Abstract

INTRODUCTION: The most appropriate treatment for stroke prevention in standalone atrial fibrillation patients with a high CHADS2VASC score contraindicated for oral anticoagulation (OAC) or novel OAC (NOAC) still needs to be defined. Percutaneous left atrial appendage (LAA) closure devices are available, but because of their endocardial positioning need a period of antiplatelet therapy (APT). This study aimed to evaluate the safety and efficacy of epicardial left atrial appendage clipping in patients contraindicated for (N)OAC and APT. METHODS AND RESULTS: We describe a standalone totally thoracoscopic LAA clipping of forty-five consecutive patients with nonvalvular atrial fibrillation (NVAF; 32 males; age, 73.1 ± 7.4 years; CHADVASC, 6.5 ± 1.1; HAS-BLED 4.9 ± 0.9) with absolute contraindications to (N)OAC. The patients were selected by a multidisciplinary Heart Team. Sixty percent had a previous ischemic stroke and 51% a history of the hemorrhagic event and 22% both. All patients were implanted with an LAA epicardial clip, guided by preoperative computed tomography and intraoperative transesophageal echocardiography. The mean procedural duration was 52.3 ± 12.6 minutes with postprocedural extubation interval of 22.8 ± 14.6 minutes. No procedure-related complications occurred. Intraprocedural transesophageal echocardiography (TEE) showed complete LAA occlusion in all patients. At a mean follow-up of 16.4 ± 9.1 months (range, 2-34), with all patients off (N)OAC or APT, no ischemic stroke or hemorrhagic complications occurred. computed tomography or TEE at follow-up demonstrated a correct LAA occlusion in all with mean stumps of 3.3 ± 2.8 mm. CONCLUSION: Thoracoscopic epicardial closure of the LAA with the AtriClip PRO2 device is a potentially safe and efficient treatment for stroke prevention in patients with NVAF contraindicated for anticoagulant therapy or APT.

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Cite This Study

Branzoli et al. (2020) conducted an observational in Nonvalvular atrial fibrillation with absolute contraindications to oral anticoagulation (n=45). Epicardial left atrial appendage clipping (AtriClip PRO2) was evaluated on Ischemic stroke or hemorrhagic complications. Epicardial left atrial appendage clipping in patients with nonvalvular atrial fibrillation contraindicated for anticoagulation resulted in 0 ischemic strokes or hemorrhagic complications at 16.4 months.

synapsesocial.com/papers/6aaa388f47961702446cb1e5 https://doi.org/10.1111/jce.14599