P5830Thoracoscopic left atrial appendectomy can prevent patients with atrial fibrillation from thromboembolism without anticoagulants

Abstract

Background: Although anticoagulation therapy is the gold standard of prophylaxis for cardiogenic thromboembolism in patients with atrial fibrillation (AF), thromboembolic events sometimes occur even when administering anticoagulants. While various left atrial appendage closure devices are developed recently, we suggest thoracoscopic left atrial appendectomy (TLAA) as a new approach to prevent cardiogenic thromboembolism in patients with AF, Purpose: We examined the effectiveness and safety of TLAA. Methods: Seventy-one consecutive patients (mean age, 70±7 years, 54 males, mean CHA2DS2-VASc score, 2.9±1.6 points) with a high risk of thromboembolism and/or bleeding were selected for TLAA. Sixty-eight of these patients had been treated with anticoagulants preoperatively. (Three patients had stopped anticoagulation therapy due to the negative side effect of bleeding.) Seventeen patients had suffered a stroke/TIA (transient ischemic attack) and two patients had a history of thromboembolism before undergoing surgery. In addition, cerebral hemorrhage had also developed in five patients preoperatively. The left atrial appendage was excised with an endoscopic linear cutter thoracoscopically in the right lateral recumbent position with differential lung ventilation. Four endoscopic ports (for the endoscope, endoscopic cutter and forceps) were normally made in the left thorax, while monitoring the procedures by transesophageal echocardiography. Results: TLAA (mean operation time 42±9 min) resulted in no mortality and no major complications. All of the patients were discharged while able to maintain their same activities of daily living in postoperative period of 3.8±1.8 days. Anticoagulants were stopped postoperatively and no cardiogenic thromboembolism events occurred, and the mean follow-up duration was 16±7 months. The rates of freedom from cardiogenic thromboembolism were significantly different between the preoperative and postoperative periods in the same patient groups (preoperatively with anticoagulants) (p<0.01 log-rank test, Figure1). Conclusion: TLAA is considered to be an effective approach for the prophylaxis of cardiogenic thromboembolism, and its safety is also deemed to be adequate. Especially for patients who are refractory to (or contraindicated for) anticoagulants, this operation would be an optimal therapeutic option. (Figure Presented).