Our Experience of Total Endoscopic Left Atrial Appendectomy in a Case for Contraindication of WATCHMAN Device

Takaharu Shimizu, Kanan Kurahashi, Satoshi Nishi, Akihiro Yoshimoto, Sei Morizumi, Yoshihiro Suematsu

Tsukuba memorial hospital, the department of cardiovascular surgery, Tsukuba Ibaraki, Japan

Date, time and location: 2018.05.26 17:00, Exhibition area, 1st Floor. Zone – C

Abstract

 A case is 73-year-old man with hypertension. He had drug-resistant and recurrent paroxysmal atrial fibrillation (Afib), followed by permanent Afib 10 years ago. 8 years later, he had cardiogenic stroke with occlusion of left carotid artery, resulting in right hemiplegia and aphasia. During that hospitalization, acute myocardial infarction and obstruction of lower limb arteries due to recurrent thromboembolism as well. Transesophageal echocardiography showed the remaining of thrombus in left atrial appendage. Under guide-line of anticoagulation therapy, DOAC has initiated. Nonetheless, one year later, the patient had the second stroke. It was considered as anticoagulation-resistant malignant thrombus, and he was initially referred to the university hospital for endovascular LAA closure with the WATCHMAN™ device. However, the size of left atrial appendage was too large, and it was concluded to be no indication for WATCHMAN™ device for him. Finally, he was referred to our clinic and total endoscopic left atrial appendectomy was successfully performed without any complication. Intraoperative transesophageal echocardiography confirmed the complete disappearance of left atrial spontaneous echo contrast. Operation time was only 28min. Postoperative course was uneventful and multi-detector-row CT showed no left atrial thrombus along the suture line, and he discharged on postoperative day 3. At follow-up, he has any thromboembolic event anymore.

 Total endoscopic left atrial appendectomy is a less invasive alternative intervention to endovascular device such as WATCHMAN™ device, and that has no size limitation different from the device. Herein, we discuss the advantage and disadvantage between LAA occlusion device and our total endoscopic left atrial appendectomy.