Results:
A 71-year-old male with morbid obesity (BMI = 39), hypertension, AF,
history of ischemic stroke, diastolic heart failure and recent
life-threatening hemorrhage after angiography, was evaluated for
intervention for stroke risk reduction. He had a
CHA2DS2-VASc score of 5 and
HAS-BLED score of 3. He underwent
thoracoscopic exclusion of LAA with the Atriclip PRO 2 device (Atricure
Inc., Cincinnati, OH) (Figure 1). The technique involved single lung
ventilation of the left side, a 5 mm camera port in the
5th and a 12 mm port in the 7thintercostal space in the mid-axillary line and a 5 mm working port in
7th intercostal space anterior to the anterior
axillary line. CO2 insufflation was used and pericardium
was opened posterior to the phrenic nerve using Harmonic Scalpel
(Ethicon. Raritan, NJ). The LAA was exposed with endoscopic kittners,
taking care not to grasp the appendage at this stage to reduce the risk
of bleeding. A 45 mm Atriclip Pro 2 device (with a closed ring) was
threaded over the tip of the LAA and carefully pulled down to the base.
Once TEE showed no residual stump, the device was deployed. However,
after removal of the delivery system, a significant residual stump was
seen (Figure 1). It was decided to obliterate this residual stump with
an open-mouth Atriclip Pro V device (Figure 2). Holding the tip of the
LAA by an endoscopic grasper, the second clip was introduced underneath
the first clip and by gentle rocking motion, it was advanced medially to
traverse the base of LAA (Video 1). TEE confirmed successful
obliteration of residual stump. Patient was extubated in the operating
room and was discharged home on the 3rd postoperative
day.