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Totally Endoscopic Robotic Left Atrial Appendage Closure Demonstrates High Success Rate

Ward, Alison F. MD; Applebaum, Robert M. MD; Toyoda, Nana MD; Fakiha, Ans MD; Neuburger, Peter J. MD; Ngai, Jennie MD; Nampiaparampil, Robert G. MD; Yaffee, David W. MD; Loulmet, Didier F. MD; Grossi, Eugene A. MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: January/February 2017 - Volume 12 - Issue 1 - p 46–49
doi: 10.1097/IMI.0000000000000330
Original Articles

Objective In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates.

Methods Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4–0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm.

Results Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow.

Conclusions We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.

From the Departments of *Cardiothoracic Surgery, †Cardiology, and ‡Anesthesia, New York University School of Medicine, New York, NY USA.

Accepted for publication December 8, 2016.

Disclosures: Peter J. Neuburger, MD, is a consultant for Medtronic, Inc, Minneapolis, MN USA. Alison F. Ward, MD, Robert M. Applebaum, MD, Nana Toyoda, MD, Ans Fakiha, MD, Jennie Ngai, MD, Robert G. Nampiaparampil, MD, David W. Yaffee, MD, Didier F. Loulmet, MD, and Eugene A. Grossi, MD, declare no conflicts of interest.

Address correspondence and reprint requests to Eugene A. Grossi, MD, NYU Langone Medical Center, 530 First Ave, Suite 9V, New York, NY 10016 USA. E-mail:

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery