Robotic-Assisted Left Atrial Appendage Exclusion with the PRO•V AtriCure Atrial Clip
Atrial fibrillation is the most common cardiac arrhythmia, affecting more than 33 million individuals worldwide (1). Anticoagulation is frequently needed to decrease the risk of stroke, but nearly 20-40% of patients at risk of stroke do not receive anticoagulation due to contraindication, bleeding, or patient/physician preferences (2, 3). Greater than 90% of cardiac emboli in nonvalvular atrial fibrillation originate in the left atrial appendage (4). The WATCHMAN™ device has been extensively studied and has emerged as an option for left atrial appendage (LAA) closure in those patients who cannot take anticoagulation, and they have had excellent results (5). Not every patient is a candidate for the WATCHMAN™ device, and the patient still requires anticoagulation for at least 45 days to allow for device endothelialization. In addition, device related thrombus (DRT) has been observed in >3% of patients with the WATCHMAN™ device (6).
Open and minimally invasive techniques have been employed for surgical LAA occlusion. The current European Society of Cardiology and American Heart Association/American College of Cardiology guidelines suggest that surgical excision/exclusion of the LAA may be considered in patients undergoing cardiac surgery or thoracoscopic atrial fibrillation surgery (grade IIB) (7). The AtriClip and AtriClip Pro (Atricure, West Chester, Ohio) have been demonstrated to have high success rates in the EXCLUDE trial (8). Closure efficacy of the atrial clip applied via total thoracoscopic approach has recently been demonstrated to have a 93.9% closure rate confirmed by angiography (9).
This video demonstrates the technique of robotic-assisted LAA occlusion with an atrial clip. The patient was an 80-year-old woman with a history of CABG x 3 1996. She had a pacemaker inserted for syncope and chronic atrial fibrillation in 2018. She was anticoagulated and had multiple gastrointestinal bleeds. She was not a candidate for the WATCHMAN™ device due to the need for temporary anticoagulation. CTA of her heart demonstrated LAA ostium = 27 x 19 mm and LAA tilted depth = 29.7 mm. She underwent robotic-assisted left atrial appendage exclusion and was discharged home two days later.
- Chugh SS, Havmoeller R, Narayanan k, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: A Global Burden of Disease 2010 study. Circulation. 2014;129:837-47.
- O’Brien EC, Holmes DN, Ansell JE, Allen LA, Hylek E, Kowey PR, et al. Physician practices regarding contraindications to oral anticoagulation and atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry. Am Heart J. 2014;167:601-609.e1.
- Kakkar AK, Mueller I, Bassand JP, Figzmaurice DA, Goldhaber SZ, Goto S, et al. Risk profiles and antithrombotic treatment of patients newly diagnosed with atrial fibrillation at risk of stroke: perspectives from the International, observational, prospective GARFIELD registry. PLoS One. 2013;8:e63479.
- Blankshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755-759.
- Reddy VY, Doshi SK, Sievert H, Buchbinder M, Neuzil P, Huber K, et al. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3 year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) trial. Circulation. 2013;127:720-729.
- Dukkipati SR, Kar S, Holmes DR, Doshi SK, Swarup V, Gibson DN, et al. Device-related thrombus after left atrial appendage closure: incidense, predictors, and outcomes. Circulation. 2018;138:874-885.
- January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland Jr. JC, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Carediology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130: 2071-2104.
- Ailawadi G, Gerdisch MW, Harvey RL, Hooker RL, Damiano Jr. RJ, Salamon T, et al. Exclusion of the left atrial appendage with a novel device: early results of a multicenter trial. J Thorac Cardiovasc Surg. 2011;142:1002-1009.
- Ellis CR, Aznaurov SG, Patel NJ, Williams JR, Sandler KL, Hoff SJ, et al. Angiographic efficacy of the Atriclip left atrial appendage exclusion device placed by minimally invasive thoracoscopic approach. JACC Clin Electrophysiol. 2017;3:1356-1365.
G. Kimble Jett is a speaker and proctor for Intuitive Surgical, Inc.