FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W2892290018> ?p ?o ?g. }

• W2892290018 endingPage "e73" @default.
• W2892290018 startingPage "e71" @default.
• W2892290018 abstract "The left atrial appendage (LAA) is a major site of clot formation in atrial fibrillation. Stand-alone thoracoscopic LAA complete closure can decrease stroke risk and may be an alternative to life-long oral anticoagulation. This report describes a technique for totally thoracoscopic LAA exclusion with an epicardial clip device. This approach provides a safe and likely more effective alternative to LAA management than other endocardial devices. The left atrial appendage (LAA) is a major site of clot formation in atrial fibrillation. Stand-alone thoracoscopic LAA complete closure can decrease stroke risk and may be an alternative to life-long oral anticoagulation. This report describes a technique for totally thoracoscopic LAA exclusion with an epicardial clip device. This approach provides a safe and likely more effective alternative to LAA management than other endocardial devices. Drs Ramlawi and Edgerton disclose a financial relationship with AtriCure. Drs Ramlawi and Edgerton disclose a financial relationship with AtriCure. During atrial fibrillation (AF), the left atrial appendage (LAA) serves as a nidus for clot formation and embolization. Patients may be better served by elimination of the LAA [1Tsai Y.C. Phan K. Munkholm-Larsen S. Tian D.H. La Meir M. Yan T.D. Surgical left atrial appendage occlusion during cardiac surgery for patients with atrial fibrillation: a meta-analysis.Eur J Cardiothorac Surg. 2015; 47: 847-854Crossref PubMed Scopus (113) Google Scholar]. Guidelines recommend that the LAA be excluded from the circulation when possible during cardiac surgical procedures in patients with AF [2Fuster V. Ryden L.E. Cannom D.S. et al.ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.Circulation. 2006; 114: e257-e354Crossref PubMed Scopus (2007) Google Scholar]. In oral anticoagulation (OAC)–intolerant patients, LAA closure decreases stroke by 75% [3Blackshear J.L. Odell J.A. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.Ann Thorac Surg. 1996; 61: 755-759Abstract Full Text PDF PubMed Scopus (1177) Google Scholar]. Currently available percutaneous endocardial LAA exclusion devices carry a significant rate of LAA patency, do not suit all LAA morphologies, and require a period of initial OAC. Totally thoracoscopic (TT) placement of an epicardial clip device AtriClip (AtriCure, Mason, OH) allows for complete LAA exclusion with minimal morbidity and no requirement for OAC. With the patient in the supine position, general anesthesia with double-lumen intubation is administered. The thorax is elevated, and the left arm is supported at the bedside with a sling, as previously described [4Edgerton J.R. Total thorascopic ablation of atrial fibrillation using the Dallas lesion set PAD, and left atrial appendectomy.Oper Tech Thorac Cardiovasc Surg. 2009; 14: 224-242Abstract Full Text Full Text PDF Scopus (11) Google Scholar]. Alternatively, the patient can be rolled slightly to the right with a bump under the left chest. Preparation extends from bed line to bed line, including the left axilla. The sternum and the groins are kept sterile and in the operating field in case either emergency sternotomy or cardiopulmonary bypass is needed. Intraoperative transesophageal echocardiography (TEE) confirms LAA patency and freedom from luminal clots. After the left lung is deflated, a 5-mm port is introduced into the left midaxillary line approximately at the third intercostal space (ICS) at the tip of the axillary hairline. Carbon dioxide insufflation aids with absorptive atelectasis, and a 30-degree 5-mm scope is introduced. Cardiac landmark and phrenic nerve identification is undertaken with the lung falling posteriorly. Frequently, the recurrent laryngeal nerve (RLN) can be seen coursing around the aorta and then cephalad. This nerve should be identified and avoided, especially during the cephalad extension of the pericardiotomy, which can be precariously close to the RLN. The LAA impression is typically seen through the pericardium, and the position of the transverse sinus is noted. This is important because the other two ports should be introduced and positioned to aim at the transverse sinus. The next port is another 5-mm port approximately at the second ICS in the midclavicular line. A spinal needle aids with verifying the optimal position before port insertion. This is repeated to position and introduce a third port caudally, approximately in the midaxillary line at the sixth ICS. This most caudad port is the most critical to position because it will be used to clip the LAA. It should be directed to the base of the LAA and be at the same level, neither too far anteriorly nor too far posteriorly. When this position is determined, a 3-cm skin incision is made, and an 11-mm port is advanced. This port site will later be enlarged to allow the passage of the clip and its application device. A 0-silk skin pursestring suture is placed, and a rundown is applied to maintain a seal around instruments. An endoscopic grasper is introduced (using the left hand) into the caudad port, and an L-cautery is introduced (using the right hand) through the cephalad port. Dissection is started over the pulmonary veins, where there is always a lymph node–bearing fat pad. The mediastinal pleura is incised, and the fat pad is swept posteriorly. This creates room to open the pericardium posterior to the phrenic nerve and directly anterior to the pulmonary veins. The pericardium is grasped just caudad to the pulmonary veins, and a hockey stick pericardiotomy is made, curving slightly posterior caudad to the pulmonary veins. A nonconductive endoscopic Kittner is passed into the pericardium to protect the heart, and the L-cautery is used to incise the pericardium on top of it. The surgeon works from caudad to cephalad until well beyond the pulmonary veins, and eventually the LAA is encountered and should be carefully protected. Identification of the RLN is crucial before the cephalad extension of the pericardial incision. An Endo Stitch (Covidien, Norwalk, CT) is placed through the anterior leaf of the pericardium just posterior to the phrenic nerve and brought out through the anterior chest for both enhanced exposure and nerve protection. The appendage is now examined for shape and anatomy. The measuring device is passed through the most caudad incision, and the base of the LAA is measured to select the proper-size clip, almost always 45 mm. Occasionally, a prominent ligament of Marshall can be seen medial and superior to the LAA underneath the left pulmonary artery. Cautery division of this ligament is often beneficial to obtain adequate epicardial clip placement medially, where an accessory LAA lobe may be located. The caudad port is removed, and the incision is extended down through the skin and the subcutaneous tissues. The intercostal muscle is spread, allowing the clip application device to be introduced with ease. The clip is verified to be fully opened within the application device before chest insertion. A gentle curve is applied to the malleable portion of the application device so that it will curve gently to the LAA base. The open device is passed over or around the tip of the appendage, which is gently teased into the device using Kittner or endoscopic forceps. The device is then lowered around the base of the appendage. The 30-degree scope should be maneuvered to allow complete visualization and to confirm whether the appendage is fully within the clip, and then the clip is closed. At this point, TEE should confirm that the entire appendage is included within the clip. If it is not, the application device can be opened and reapplied. When the position is confirmed to be satisfactory, the clip is deployed, and the applicator is gently removed. The pericardium is carefully reapproximated with one Endo Stitch. If closure of the pericardium places any torsion on the clip, this step is abandoned. A chest tube is introduced through the most caudad incision and is advanced toward the apex anterior to the hilum. After a multilevel intercostal block, the lung is reinflated. All ports are removed, suction is placed on the chest tube, and all incisions are closed and infiltrated with local anesthesia. The patient is then awakened and transported to the recovery room with plans made for discharge on the first postoperative day (Fig 1). Imaging at 1 year is shown (Fig 2), confirming complete and flush occlusion.Fig 2Computed tomographic angiogram at 1 year confirming total flush left atrial appendage occlusion.View Large Image Figure ViewerDownload Hi-res image Download (PPT) If a tear is sustained during LAA manipulation, quick action is necessary. The tear will often have been sustained at the tip of the appendage as a result of an overly forceful grasp. In this event, the clip is immediately closed to cease the hemorrhage. If the clip position was suboptimal, the surgeon then has two options: (1) attempt to grasp the appendage over the bleeding site, reopen the clip, and more optimally position it; or (2) a 0-PDS Endoloop (Ethicon, Somerville, NJ) can be positioned around the base of the LAA underneath the clip and then cautiously tightened under TEE guidance to confirm that the remaining lumen of the appendage is occluded. In the event of brisk hemorrhage, a sponge stick is introduced through the most caudad port site, and the LAA is compressed to secure hemostasis. The surgeon then has options: (1) initiate cardiopulmonary bypass through the left groin, or (2) proceed to thoracotomy to control the LAA directly. Median sternotomy is rarely needed, and a left anterior thoracotomy will usually suffice. This technique maybe an alternative to OAC in AF. This TT LAA clip procedure is safe and likely more effective than endocardial devices. Further larger studies are required. There was no funding for this work. It is free from outside interests in controlling the design of the study, acquisition of data, collection, analysis and interpretation of data, and the authors have freedom to disclose all results fully. The authors wish to thank Lindsey Philpot, MPH, and Kelli R. Trungale, MLS, ELS, for editorial assistance." @default.
• W2892290018 created "2018-09-27" @default.
• W2892290018 creator A5013308884 @default.
• W2892290018 creator A5019195401 @default.
• W2892290018 creator A5062235641 @default.
• W2892290018 date "2019-01-01" @default.
• W2892290018 modified "2023-09-27" @default.
• W2892290018 title "Totally Thoracoscopic Closure of the Left Atrial Appendage" @default.
• W2892290018 cites W2000573223 @default.
• W2892290018 cites W2053482681 @default.
• W2892290018 cites W2099588187 @default.
• W2892290018 cites W4247874809 @default.
• W2892290018 doi "https://doi.org/10.1016/j.athoracsur.2018.07.046" @default.
• W2892290018 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/30240767" @default.
• W2892290018 hasPublicationYear "2019" @default.
• W2892290018 type Work @default.
• W2892290018 sameAs 2892290018 @default.
• W2892290018 citedByCount "4" @default.
• W2892290018 countsByYear W28922900182019 @default.
• W2892290018 countsByYear W28922900182020 @default.
• W2892290018 countsByYear W28922900182023 @default.
• W2892290018 crossrefType "journal-article" @default.
• W2892290018 hasAuthorship W2892290018A5013308884 @default.
• W2892290018 hasAuthorship W2892290018A5019195401 @default.
• W2892290018 hasAuthorship W2892290018A5062235641 @default.
• W2892290018 hasBestOaLocation W28922900181 @default.
• W2892290018 hasConcept C105702510 @default.
• W2892290018 hasConcept C126322002 @default.
• W2892290018 hasConcept C141071460 @default.
• W2892290018 hasConcept C146834321 @default.
• W2892290018 hasConcept C162324750 @default.
• W2892290018 hasConcept C164705383 @default.
• W2892290018 hasConcept C2775914520 @default.
• W2892290018 hasConcept C2779056968 @default.
• W2892290018 hasConcept C2779161974 @default.
• W2892290018 hasConcept C2910272107 @default.
• W2892290018 hasConcept C34447519 @default.
• W2892290018 hasConcept C41451933 @default.
• W2892290018 hasConcept C71924100 @default.
• W2892290018 hasConceptScore W2892290018C105702510 @default.
• W2892290018 hasConceptScore W2892290018C126322002 @default.
• W2892290018 hasConceptScore W2892290018C141071460 @default.
• W2892290018 hasConceptScore W2892290018C146834321 @default.
• W2892290018 hasConceptScore W2892290018C162324750 @default.
• W2892290018 hasConceptScore W2892290018C164705383 @default.
• W2892290018 hasConceptScore W2892290018C2775914520 @default.
• W2892290018 hasConceptScore W2892290018C2779056968 @default.
• W2892290018 hasConceptScore W2892290018C2779161974 @default.
• W2892290018 hasConceptScore W2892290018C2910272107 @default.
• W2892290018 hasConceptScore W2892290018C34447519 @default.
• W2892290018 hasConceptScore W2892290018C41451933 @default.
• W2892290018 hasConceptScore W2892290018C71924100 @default.
• W2892290018 hasIssue "1" @default.
• W2892290018 hasLocation W28922900181 @default.
• W2892290018 hasLocation W28922900182 @default.
• W2892290018 hasOpenAccess W2892290018 @default.
• W2892290018 hasPrimaryLocation W28922900181 @default.
• W2892290018 hasRelatedWork W1978291450 @default.
• W2892290018 hasRelatedWork W2003814312 @default.
• W2892290018 hasRelatedWork W2034513761 @default.
• W2892290018 hasRelatedWork W2045853943 @default.
• W2892290018 hasRelatedWork W2053292521 @default.
• W2892290018 hasRelatedWork W2083182904 @default.
• W2892290018 hasRelatedWork W2368580361 @default.
• W2892290018 hasRelatedWork W2745741657 @default.
• W2892290018 hasRelatedWork W2803188355 @default.
• W2892290018 hasRelatedWork W2900300302 @default.
• W2892290018 hasVolume "107" @default.
• W2892290018 isParatext "false" @default.
• W2892290018 isRetracted "false" @default.
• W2892290018 magId "2892290018" @default.
• W2892290018 workType "article" @default.