Feasibility, safety and efficacy of a novel simplified approach for epicardial ligation

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 though its advantage of avoiding any device implantation and its obligatory anticoagulation afterwards in this high risk patient cohort.

We would like to introduce a novel simplified and fast way of epicardial ligation in up to now 18 patients.

Method

All patients (mean age 75,2 years, 13 male, mean CHADSVASC 4,1, 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 pericardial puncture in an anterior approach, 2 wires were left inside the pericardium. Transseptal puncture wa guided under TOE and 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 (waiting time of 5 minutes included) 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. Follow up was performed after 6, 12 and 50 weeks with a TOE control and documentation of any clinical event.

Results

In 15 patients epicardial closure was successful, in 3 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 13 min. FUP data are right now available in 12 patients: 1 patient with heavy smog developed a thrombus, resoluted with NOAK and treated now with half NOAK. 1 patient developed a gap of 3 mm. No pericarditis or any complication occurred.

Conclusion

The novel epicardial ligation approach without over the wire technique is fast, safe and effective. Flouroscopy and proceduretime is compareable to the endocardial approach. First data of FUP show 1 thrombus and 1 central gap. Further data are needed for confirmation of these preliminary promising results.