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.