Thoracoscopic Stand-Alone Left Atrial Appendectomy for Thromboembolism Prevention in Nonvalvular Atrial Fibrillation

Study Questions:

What is the efficacy of thoracoscopic stand-alone left atrial appendectomy (LAA) for thromboembolism prevention in nonvalvular atrial fibrillation (AF)?

Methods:

Thirty patients (mean age, 74 ± 5.0 years) who had had thromboembolisms were selected. A subgroup of 21 patients (mean age, 75 years; mean CHA2DS2 VASc score, 4.5) urgently needed an alternative treatment to anticoagulation: warfarin was contraindicated due to hemorrhagic side effects in 13 patients, the international normalized ratio was uncontrollable in seven patients, and transient ischemic attacks had developed immediately after the warfarin dose was reduced for oncological treatment in one patient. The LAA was thoracoscopically excised with an endoscopic cutter.

Results:

Thoracoscopic appendectomy (mean operating time 32 minutes, switched to mini-thoracotomy in two cases) led to no mortality and no major complications. Three-month postoperative three-dimensional enhanced computed tomography, performed with patients’ consent, confirmed the completeness of the appendectomy. Patients have been followed for 1-38 months (mean, 16 ± 9.7 months [18 ± 9.4 months for the subgroup]). One patient died of breast cancer 28 months after surgery. Despite discontinued anticoagulation, no patients have experienced recurrence of thromboembolism.

Conclusions:

The authors concluded that thoracoscopic stand-alone appendectomy is potentially safe and may allow surgeons to achieve relatively simple, complete LAA closure.

Perspective:

This pilot study suggests that thoracoscopic stand-alone appendectomy is potentially safe, and may permit surgeons to remove the LAA relatively simply and completely. This procedure may benefit patients who are at great risk of thromboembolisms, and in whom anticoagulation is no longer tolerable. The experience to date is insufficient to address potential safety concerns associated with applying the technique, and additional prospective studies are needed to assess efficacy and safety of thoracoscopic stand-alone appendectomy in patients with nonvalvular AF.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Thromboembolism, Thoracotomy, Blood Coagulation, Heart Atria, Ischemic Attack, Transient, Atrial Appendage, Warfarin, Breast Neoplasms, Atrial Fibrillation


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