Introduction:
Bleeding complications in high risk patients with atrial fibrillation can be prevented by closure of the left atrial appendage (LAA) as an alternative to oral anticoagulation. Several endocardial devices are available for LAA closure each associated with different advantages or challenges. Epicardial ligation using the LARIAT has not become accepted widely due to its time consuming complexity.
We would like to introduce a novel simplified and fast way of epicardial ligation in up to now 10 patients.
Method:
All patients (mean age 77,9 years, 9 male, mean CHADSVASC 4, mean HESBLED score 3,1) were screened with a cardiac CT for potential contraindications for epicardial ligation of the LAA. After having given the informed consent patients were put under analgosedation. After puncturing the groin pericardial puncture was performed in an anterior approach, 2 wires were left inside the pericardium. After transseptal puncture under transesophageal echo (TOE) guidance a pigtail catheter was positioned in the LAA. Biplane angiogram of the LAA was performed. Via the epicardial access the LARIAT system was advanced over the LAA under fluoroscopy without any wire guidance. Having reached a proper position the snare was closed under TOE control. In case of an optimal result the sutures were tightened twice and the final result was documented with angiogram and TOE. After cutting the suture a drainage was positioned in the pericardium removed after 12-24 hours. For pericarditis prevention all patients were treated with colchicum started the day before.
Results:
In 9 patients epicardial closure was successful, in 1 patient the procedure failed due to pericardial adhesions, in 1 patient the traditional approach using the magnets had to be applied due to a very small LAA. This had been anticipated before. Mean procedure time was 60,5 min, mean LA time was 24,1 min, mean radiation time 10 min. FUP data are right now available in 4 patients with no central gap or thrombus in the toe. No pericarditis or any complication occurred.
Conclusion:
The novel epicardial ligation approach without over the wire technique is feasable (except in very small atria), safe and effective. Procedure time and radiation time are low and first data of FUP shows no long term complication like thrombus or central gap. Further data are needed for confirmation of these preliminary promising results.
