Thoracoscopic stapler-and-loop technique for left atrial appendage closure in nonvalvular atrial fibrillation: Mid-term outcomes in 201 patients

Background Left atrial appendage (LAA) closure can be an alternative to oral anticoagulation to prevent cardiogenic thromboembolisms in patients with nonvalvular atrial fibrillation. Objective The purpose of this study was to retrospectively evaluate the safety, completeness, and mid-term prevention of our thoracoscopic stapler-and-loop technique for LAA closure. Methods Patients operated on between October 2008 and February 2017 were reviewed. Endoscopic stapler and ligation loops were used. Patients received 1 month of anticoagulation before discontinuation. Hospital death and procedure-related major complications (thromboembolism, hemorrhagic events, phrenic palsy) were the primary composite endpoint for safety, and cardiogenic thromboembolisms were the endpoint for prevention. Brain magnetic resonance imaging investigated new thromboembolic spots 1 year after surgery. Results There were 201 patients (118 men, 83 women) with a mean age of 74 years (range 68–94) years, mean CHA2DS2-VASc score (± SD) 4.1 ±1.4, and mean HAS-BLED score 2.9 ± 1.0. Mean operation time was 28 minutes. All LAAs were removed, and intraoperative transesophageal echocardiography confirmed completeness of the closure in each patient. No hospital deaths or major procedure-related complications occurred. Follow-up results for 198 patients (98%) over a mean period of 48 months (range 12–110) revealed that 2 patients developed cardiogenic thromboembolisms (0.25 event per 100 patient-years). Magnetic resonance imaging of 51 patients with a mean CHA2DS2-VASc score of 4.7 ± 1.6 revealed 1 new small spot in each of 2 patients (3.9%; 3.9 spots per 100 patient-years). Conclusion Our thoracoscopic stapler-and-loop technique swiftly, safely, and completely closed LAAs in patients with nonvalvular atrial fibrillation and provided acceptable mid-term prevention without anticoagulation.