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LEFT ATRIAL APPENDAGE OBLITERATION IN ATRIAL FIBRILLATION

Thoracoscopic extracardiac obliteration of the left atrial appendage for stroke risk reduction in atrial fibrillation

Joseph L. Blackshear, MD^*,*, W. Dudley Johnson, MD, John A. Odell, MD^*, Vickie S. Baker, RN^*, Mary Howard, RN, Lesly Pearce, MS, Christopher Stone, MD, Douglas L. Packer, MD and Hartzell V. Schaff, MD

^* Mayo Clinic Jacksonville, Jacksonville, Florida, USA
W. Dudley Johnson Heart Care Center, Milwaukee, Wisconsin, USA
Biostatistical Consultant, Minot, North Dakota, USA
Mayo Clinic, Rochester, Minnesota, USA

Manuscript received December 5, 2002; revised manuscript received January 30, 2003, accepted February 20, 2003.

^* Reprint requests and correspondence: Dr. Joseph L. Blackshear, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, Florida 32224, USA.
blackshear.joseph{at}mayo.edu

OBJECTIVES: We evaluated left atrial appendage obliteration in high-risk patients with atrial fibrillation (AF).

BACKGROUND: Left atrial appendage thrombosis and embolization is the principal mechanism of stroke in AF. Anticoagulation is underutilized and often contraindicated.

METHODS: Thoracoscopic Left Appendage, Total Obliteration, No cardiac Invasion (LAPTONI) was undertaken with a loop snare in eight patients and a stapler in seven patients, median age 71 years, with clinical risk factors for stroke and with an absolute contraindication to or failure of prior thrombosis prevention with warfarin. Eleven patients had a history of prior thromboembolism. One patient took sustained warfarin during follow-up.

RESULTS: The LAPTONI procedure was completed in 14 of 15 patients, and 1 patient required urgent conversion to open thoracotomy because of bleeding. Patients have been followed up for 8 to 60 months, mean 42 ± 14 months. One fatal stroke occurred 55 months after surgery, and one non-disabling stroke three months after surgery. Two other deaths occurred, one after coronary bypass surgery and the other from hepatic failure. The subgroup of 11 patients with prior thromboembolism had an annualized rate of stroke of 5.2% per year (95% confidence interval [CI] 1.3 to 21) after LAPTONI, which compares to a rate of 13% per year (95% CI 9.0 to 19) for similar aspirin-treated patients from the Stroke Prevention in Atrial Fibrillation trials (p = 0.15).

CONCLUSIONS: The LAPTONI procedure appears technically feasible without immediate disabling neurologic morbidity or mortality, and it demonstrates low post-operative event rates and a statistical trend toward thromboembolic risk reduction in high-risk AF patients.

Key Words: AFatrial fibrillation • AFIAtrial Fibrillation Investigators • EAFTEuropean Atrial Fibrillation Trial • LAleft atrial • LAPTONILeft Appendage, Total Obliteration, No cardiac Invasion • SPAFStroke Prevention in Atrial Fibrillation • TEEtransesophageal echocardiography

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