Complete elimination of the left atrial appendage using a surgical stapler.
Central Message.
In minimally invasive cardiac surgery, a surgical stapler is sometimes useful as a bailout device for incomplete elimination of the left atrial appendage.
Various methods have been developed for left atrial appendage (LAA) elimination.1,2 However, most of these methods are unreliable for complete elimination of the LAA base.1,2 Therefore, external device closure of the LAA has been a topic of interest in cardiac surgery.3 Limited workspace may make this procedure difficult to implement in minimally invasive cardiac surgery (MICS), particularly when the LAA base is large.
In this report, we describe our experience of performing a bailout procedure with a surgical stapler following unsuccessful external LAA clipping during MICS. Data were collected with the approval of the patient and the Regional Ethics Committee of Asahikawa Medical University (approval No. 20511, December 10, 2019).
Case Presentation
A 78-year-old man was admitted to our unit for mitral valve plasty for severe mitral valve regurgitation, a maze operation, and LAA elimination for chronic atrial fibrillation.
A small right-sided thoracotomy was performed in the fourth intercostal space. Bicaval venous drainage via the right jugular and right femoral veins was performed to place a cannula through the right atrium, and right femoral arterial cannulation was performed. After aortic crossclamping with a Cygnet flexible clamp (Vitalitec), initial cardioplegia was administered antigradely, followed by left atriotomy with intermittent cardioplegia administration.
LAA elimination with external device closure (AtriClip PRO; AtriCure) was attempted before mitral valve surgery. The LAA was exposed by gentle retraction of the ascending aorta using a left atrial retractor (Adams-Yozu Mini-Valve System, Geister) via the transverse sinus.
First, the distal edge of the LAA was picked up gently using forceps and the LAA base location was confirmed. Then, the LAA shape and base length were checked with a flexible sizer, referred to as a selection guide. In this patient, the LAA was quite large and bulky. The LAA base length was approximately 50 mm. The largest size (50 mm) of this product (AtriClip) was used to deliver the clip to the LAA base. However, it was difficult to draw the distal portion of the LAA forward and position the clip on the LAA base. After complete release of the clip onto the appendage, it was found that the LAA elimination was incomplete, and a stump was still present (Video 1). Therefore, we considered oversewing the LAA remnant from the inside of the left atrium. However, this was not performed to avoid injury to the proximal segment of the left circumflex artery due to oversewing of the LAA with a big bite.
To complete LAA elimination, we grasped the clip and raised it up to confirm the location of the LAA base again. The appendage was completely resected by firing a surgical stapler (Endo GIA Tri-Staple 60; Medtronic) (Video 2). Then, mitral valve plasty and left atrium ablation were performed. From the inside of the left atrium, no trabeculation or residual pouch was observed at the LAA orifice.
Surgical bleeding from the site of LAA elimination was not evident. Besides, we found no residual flow into the LAA in intraoperative transesophageal echocardiography when the patient was weaned off cardiopulmonary bypass. The complete exclusion of the LAA base was confirmed by the LAA specimen (Figure 1) and postoperative computed tomography (Figure 2, A and B).
Figure 1.
Left atrial appendage (LAA) specimen. Asterisk (∗) indicates the malposition of the AtriClip PRO (Atricure), and arrow indicates the suture line on the LAA base made by the surgical stapler (Endo GIA Tri-Staple 60; Medtronic).
Figure 2.
A and B, Postoperative enhanced computed tomography showed complete elimination of left atrial appendage (LAA). Arrows indicate the track of the surgical stapler.
The postoperative course of this patient was uneventful. Twelve months have passed since the operation, and the patient is free from atrial fibrillation and thromboembolic or bleeding events at present.
Discussion
If LAA elimination is performed through a sternotomy, the LAA size or shape has no effect on making complete exclusion without failure. Moreover, it is usually not difficult to confirm the success of the deployment of a surgical clip in MICS by the naked eye. However, the handling of an enlarged LAA in MICS is sometimes difficult.
External device closure of the LAA has been recognized as a simple way to perform LAA occlusion, especially in MICS, in which the surgical workspace is limited and the distance from the right chest wall to the target is quite long, making it difficult to grasp the LAA manually.3 In our unit, we have adopted a surgical clip (AtriClip PRO/AtriClip Flex) as a first line for LAA elimination in both MICS and midsternotomy approaches because it is more atraumatic than the surgical stapler. We have never used a surgical stapler for this purpose as a first-line treatment. Furthermore, it was possible to confirm the deployment of the AtriClip via the transverse sinus in MICS.
External elimination of LAA in MICS has a drawback; namely, it is difficult to visually confirm the distal edge of the LAA, which sometimes leads to unexpected incomplete exclusion of the LAA. In this case, the surgeon's line of sight and the direction of the manipulated area were the same, which prevented sufficient visualization of the manipulated area at the moment of deployment. At present, it is safer and more reasonable to use a surgical stapler in MICS to attack an enlarged LAA, defined as an LAA base length >50 mm, than to use an LAA clip.
Another pitfall of LAA elimination is the possibility of a torn LAA, the occurrence of which during MICS could have undesirable outcomes. Pinching or gently retracting the LAA with long forceps can be technically demanding. In this situation, positioning the clip at the LAA base tends to be unsuccessful.
The AtriClip device is made of a polyurethane tube coated with a polyester fabric. The fabric is easy to pinch. In this context, the surgical stapler provides a good opportunity to bail out with gentle retraction of the LAA by lifting this clip upward to visualize the LAA base more clearly. Additionally, the delivery of the blade of the surgical stapler to the LAA base was not stressful because the direction of the instrument's tip was the same as the axis connecting the fourth intercostal space and the LAA base.
Previous studies reported the feasibility of using various surgical staplers.4,5 Ohtsuka and colleagues5 reported their outcomes of thoracoscopic LAA exclusion with an endoscopic linear cutter without any mortality or major complications. A benefit of the use of a stapler is that it enables us to exclude a relatively big LAA tissue, although AtriClip is more atraumatic when deployed.
The LAA base is anatomically curved, whereas a staple line is straight. However, the line of the LAA base can be straightened by mild compression of the LAA base imposed by the surgical stapler, which makes it provide complete elimination of LAA.
Conclusions
The handling of an enlarged LAA in MICS is difficult due to limited workspace, which could lead to malposition of the LAA clip. In such a situation, the use of a surgical stapler as a bailout procedure for unsuccessful LAA clipping in MICS can be helpful.
Footnotes
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Supplementary Data
Left atrial appendage elimination was attempted with an external device (AtriClip PRO; Atricure). However, it was found that LAA elimination was incomplete. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00001-9/fulltext.
The clipped left atrial appendage was raised and resected completely by firing a surgical stapler (Endo GIA Tri-Staple 60; Medtronic). Video available at: https://www.jtcvs.org/article/S2666-2507(23)00001-9/fulltext.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Left atrial appendage elimination was attempted with an external device (AtriClip PRO; Atricure). However, it was found that LAA elimination was incomplete. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00001-9/fulltext.
The clipped left atrial appendage was raised and resected completely by firing a surgical stapler (Endo GIA Tri-Staple 60; Medtronic). Video available at: https://www.jtcvs.org/article/S2666-2507(23)00001-9/fulltext.