Efficacy of clips versus staplers for left atrial appendage in the thoracoscopic treatment of atrial fibrillation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

MA Nan , BAO Chunrong , WEI Ke , ZHANG Yunjiao , ZHANG Li ,  MEI Ju

Department of Cardiothoracic Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, P. R. China;

Corresponding author：

MEI Ju, Email: ju_mei63@126.com

Keywords：

Atrial fibrillation; left atrial appendage; stroke; thoracoscopy

DOI：

10.7507/1007-4848.202202010

Video：

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Objective To summarize the efficacy of clips and staplers for left atrial appendage in the thoracoscopic treatment of atrial fibrillation. Methods The clinical data of patients with atrial fibrillation treated in Xinhua Hospital from 2015 to 2016 were retrospectively analyzed. All patients received Mei's minimally invasive surgery for atrial fibrillation. Among them, patients were recruited in a clip group by clipping the left atrial appendage. The other patients were recruited in a stapler group to resect the left atrial appendage by stapler. Follow-up was conducted by outpatient clinic and telephone. Postoperative heart rhythm was recorded by the patient's symptoms, electrocardiogram and 24 h holter. Cranial magnetic resonance, cardiac CT and echocardiography were performed at least once during follow-up. Results There were 30 patients in the clip group, including 20 males and 10 females, with an average age of 65.7±7.1 years. There were 30 patients in the stapler group, including 20 males and 10 females with an average age of 66.8±5.4 years. All patients successfully received the procedure, with no conversion to thoracotomy or perioperative death. Sinus rhythm was maintained at discharge in 56 (93.3%) patients. Till June 2020, 59 patients were followed up for 42-66 (54.1±7.3) months and 1 patient in the clip group was lost. The residual length of the left atrial appendage was 3.9±1.8 mm in the clip group and 3.9±2.8 mm in the stapler group, and there was no statistical difference between the two groups (P=0.910). Kaplan-Meier curve indicated that there was no statistical difference in the maintenance of sinus rhythm between the two groups (P=0.757). During the follow-up period, all patients had no cerebrovascular adverse events such as stroke or embolism. Conclusion Clipping and resection of the left atrial appendage in thoracoscopic atrial fibrillation surgery are both safe and effective methods, which effectively prevent stroke. The atrial appendage clip makes the minimally invasive surgical intervention of the left atrial appendage safer and more convenient.

Citation： MA Nan, BAO Chunrong, WEI Ke, ZHANG Yunjiao, ZHANG Li, MEI Ju. Efficacy of clips versus staplers for left atrial appendage in the thoracoscopic treatment of atrial fibrillation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(11): 1604-1608. doi: 10.7507/1007-4848.202202010 Copy

1.	中国研究型医院协会, 中国医师协会房颤专家委员会. 心房颤动外科治疗中国专家共识2020版. 中华胸心血管外科杂志, 2021, 37(3): 129-144.
2.	Wang X, Fu Q, Song F, et al. Prevalence of atrial fibrillation in different socioeconomic regions of China and its association with stroke: Results from a national stroke screening survey. Int J Cardiol, 2018, 271: 92-97.
3.	January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 2019, 74(1): 104-132.
4.	Escudero-Martínez I, Morales-Caba L, Segura T. Atrial fibrillation and stroke: A review and new insights. Trends Cardiovasc Med, 2021, S1050-1738(21): 00145-6.
5.	Barra S, Providência R. Anticoagulation in atrial fibrillation. Heart, 2021, 107(5): 419-427.
6.	Schnabel RB, Haeusler KG, Healey JS, et al. Searching for atrial fibrillation poststroke: A white paper of the AF-SCREEN International Collaboration. Circulation, 2019, 140(22): 1834-1850.
7.	中华医学会心电生理和起搏分会, 中华医学会心血管病分会, 中国医师协会心律学专业委员会. 左心耳干预预防心房颤动患者血栓栓塞事件: 目前的认识和建议-2019. 中国心脏起搏与心电生理杂志, 2019, 33(5): 17.
8.	Ajmal M, Sipra QUAR, Pecci C, et al. Feasibility of left atrial appendage closure in atrial fibrillation patients with a history of intracranial bleeding: A systematic review of observational studies. J Interv Cardiol, 2020, 2020: 1575839.
9.	Mei J, Ma N, Ding F, et al. Complete thoracoscopic ablation of the left atrium via the left chest for treatment of lone atrial fibrillation. J Thorac Cardiovasc Surg, 2014, 147(1): 242-246.
10.	马南, 姜兆磊, 陈飞, 等. 梅氏微创消融术治疗心房颤动207例. 中国胸心血管外科临床杂志, 2015, 22(11): 996-999.
11.	Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J, 2021, 42(5): 373-498.
12.	Cox JL. Mechanical closure of the left atrial appendage: Is it time to be more aggressive? J Thorac Cardiovasc Surg, 2013, 146(5): 1018-1027.
13.	Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg, 1996, 61(2): 755-759.
14.	Essa H, Hill AM, Lip GYH. Atrial fibrillation and stroke. Card Electrophysiol Clin, 2021, 13(1): 243-255.
15.	Murtaza G, Boda U, Turagam MK, et al. Risks and benefits of removal of the left atrial appendage. Curr Cardiol Rep, 2020, 22(11): 129.
16.	Boyle PM, Del Álamo JC, Akoum N. Fibrosis, atrial fibrillation and stroke: Clinical updates and emerging mechanistic models. Heart, 2021, 107(2): 99-105.
17.	Murtaza G, Yarlagadda B, Akella K, et al. Role of the left atrial appendage in systemic homeostasis, arrhythmogenesis, and beyond. Card Electrophysiol Clin, 2020, 12(1): 21-28.
18.	Wintgens LIS, Maarse M, Swaans MJ, et al. The WATCHMAN left atrial appendage closure device for patients with atrial fibrillation: Current status and future perspectives. Expert Rev Med Devices, 2020, 17(7): 615-626.
19.	Wunderlich NC, Lorch GC, Honold J, et al. Why follow-up examinations after left atrial appendage closure are important: Detection of complications during follow-up and how to deal with them. Curr Cardiol Rep, 2020, 22(10): 113.
20.	Rosati F, de Maat GE, Valente MAE, et al. Surgical clip closure of the left atrial appendage. J Cardiovasc Electrophysiol, 2021, 32(10): 2865-2872.
21.	Kanderian AS, Gillinov AM, Pettersson GB, et al. Success of surgical left atrial appendage closure: Assessment by transesophageal echocardiography. J Am Coll Cardiol, 2008, 52(11): 924-929.
22.	Aryana A, Singh SK, Singh SM, et al. Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization. Heart Rhythm, 2015, 12(7): 1431-1437.

1. 中国研究型医院协会, 中国医师协会房颤专家委员会. 心房颤动外科治疗中国专家共识2020版. 中华胸心血管外科杂志, 2021, 37(3): 129-144.
2. Wang X, Fu Q, Song F, et al. Prevalence of atrial fibrillation in different socioeconomic regions of China and its association with stroke: Results from a national stroke screening survey. Int J Cardiol, 2018, 271: 92-97.
3. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 2019, 74(1): 104-132.
4. Escudero-Martínez I, Morales-Caba L, Segura T. Atrial fibrillation and stroke: A review and new insights. Trends Cardiovasc Med, 2021, S1050-1738(21): 00145-6.
5. Barra S, Providência R. Anticoagulation in atrial fibrillation. Heart, 2021, 107(5): 419-427.
6. Schnabel RB, Haeusler KG, Healey JS, et al. Searching for atrial fibrillation poststroke: A white paper of the AF-SCREEN International Collaboration. Circulation, 2019, 140(22): 1834-1850.
7. 中华医学会心电生理和起搏分会, 中华医学会心血管病分会, 中国医师协会心律学专业委员会. 左心耳干预预防心房颤动患者血栓栓塞事件: 目前的认识和建议-2019. 中国心脏起搏与心电生理杂志, 2019, 33(5): 17.
8. Ajmal M, Sipra QUAR, Pecci C, et al. Feasibility of left atrial appendage closure in atrial fibrillation patients with a history of intracranial bleeding: A systematic review of observational studies. J Interv Cardiol, 2020, 2020: 1575839.
9. Mei J, Ma N, Ding F, et al. Complete thoracoscopic ablation of the left atrium via the left chest for treatment of lone atrial fibrillation. J Thorac Cardiovasc Surg, 2014, 147(1): 242-246.
10. 马南, 姜兆磊, 陈飞, 等. 梅氏微创消融术治疗心房颤动207例. 中国胸心血管外科临床杂志, 2015, 22(11): 996-999.
11. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J, 2021, 42(5): 373-498.
12. Cox JL. Mechanical closure of the left atrial appendage: Is it time to be more aggressive? J Thorac Cardiovasc Surg, 2013, 146(5): 1018-1027.
13. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg, 1996, 61(2): 755-759.
14. Essa H, Hill AM, Lip GYH. Atrial fibrillation and stroke. Card Electrophysiol Clin, 2021, 13(1): 243-255.
15. Murtaza G, Boda U, Turagam MK, et al. Risks and benefits of removal of the left atrial appendage. Curr Cardiol Rep, 2020, 22(11): 129.
16. Boyle PM, Del Álamo JC, Akoum N. Fibrosis, atrial fibrillation and stroke: Clinical updates and emerging mechanistic models. Heart, 2021, 107(2): 99-105.
17. Murtaza G, Yarlagadda B, Akella K, et al. Role of the left atrial appendage in systemic homeostasis, arrhythmogenesis, and beyond. Card Electrophysiol Clin, 2020, 12(1): 21-28.
18. Wintgens LIS, Maarse M, Swaans MJ, et al. The WATCHMAN left atrial appendage closure device for patients with atrial fibrillation: Current status and future perspectives. Expert Rev Med Devices, 2020, 17(7): 615-626.
19. Wunderlich NC, Lorch GC, Honold J, et al. Why follow-up examinations after left atrial appendage closure are important: Detection of complications during follow-up and how to deal with them. Curr Cardiol Rep, 2020, 22(10): 113.
20. Rosati F, de Maat GE, Valente MAE, et al. Surgical clip closure of the left atrial appendage. J Cardiovasc Electrophysiol, 2021, 32(10): 2865-2872.
21. Kanderian AS, Gillinov AM, Pettersson GB, et al. Success of surgical left atrial appendage closure: Assessment by transesophageal echocardiography. J Am Coll Cardiol, 2008, 52(11): 924-929.
22. Aryana A, Singh SK, Singh SM, et al. Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization. Heart Rhythm, 2015, 12(7): 1431-1437.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Efficacy of clips versus staplers for left atrial appendage in the thoracoscopic treatment of atrial fibrillation

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