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Initial Experience With Minimally Invasive Surgical Exclusion of the Left Atrial Appendage With an Epicardial Clip

Smith, Nathan E. MD; Joseph, Jeevan MD; Morgan, John MD; Masroor, Saqib MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: January/February 2017 - Volume 12 - Issue 1 - p 28–32
doi: 10.1097/IMI.0000000000000339
Original Articles

Objective Atrial fibrillation (AF) is the primary cardiac abnormality associated with ischemic stroke. Atrial fibrillation affects 2.7 million people with a stroke rate of 3.5% per year. Most of the emboli in patients with nonvalvular AF originate in the left atrial appendage (LAA). Surgical exclusion of the LAA decreases the yearly risk of stroke to 0.7% when combined with a Maze procedure. Traditional oversewing the LAA from inside the left atrium is associated with a significant number of recanalizations of LAA. An alternate technique is epicardial clipping, which has been approved through sternotomy for permanent exclusion of LAA. We present our initial experience of epicardial clipping of the LAA using a minimally invasive approach.

Methods Between May 2012 and December 2015, a total of 24 consecutive patients underwent minimally invasive, echo-guided epicardial clipping. Indications for the procedure were persistent (n = 12) or paroxysmal (n = 12) AF in patients who could not tolerate full anticoagulation because of a combination of gastrointestinal bleeding (n = 7), hemorrhagic stroke (n = 5), ischemic stroke (n = 5), intramuscular bleeding (n = 3), falls (n = 2), urinary tract bleeding (n = 2), subdural hematoma (n = 1), traumatic aortic intramural hematoma (n = 1), and lifestyle and career practices inconsistent with anticoagulation (n = 1). The clipping was performed through three 5-mm ports in the left seventh intercostal space (n = 22) or a 5-cm incision in the fifth intercostal space (n = 2). Echocardiography was performed to exclude the presence of LAA thrombus and to confirm exclusion of LAA before final deployment of the clip.

Results The mean age was 73.6 years. The mean CHA2DS2VASC score was 4.7 and the mean HAS-BLED score was 3.8. The mean postoperative length of stay was 6.4 days. One patient died of stroke-related complications 10 days after successful clipping, and two patients required thoracentesis to drain recurrent pleural effusions. All patients had successful exclusion of LAA defined as residual sac of less than 1 cm.

Conclusions Isolated epicardial left atrial clipping is a safe treatment option in high-risk patients with AF. Long-term success in preventing stroke is still to be determined, but short-term results are very encouraging.

From the Mercy Hospital and Kendall Regional Medical Center, Florida Heart and Vascular Care, Miami, FL USA; and Aventura Medical Center, Aventura, FL USA.

Accepted for publication December 5, 2016.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 15–18, 2016, Montreal, Quebec, Canada.

Disclosures: Saqib Masroor, MD, is a consultant for AtriCure, Inc, West Chester, OH USA. Nathan E. Smith, MD, Jeevan Joseph, MD, and John Morgan, MD, report no conflicts of interest.

Address correspondence and reprint requests to Nathan E. Smith, MD, 12989 SW 135th Terrace, Miami, FL 33186 USA. E-mail:

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery