\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Management of Residual Left Atrial Appendage Stump with a Second
Epicardial Clip.}



\author[1]{Saqib Masroor}%
\author[1]{Abdullah Nasif}%
\affil[1]{The University of Toledo Department of Surgery}%


\vspace{-1em}



  
  \date{March 14, 2025}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Epicardial exclusion of LAA has gained increasing popularity since its
introduction in 2009. While the clip has demonstrated a success rate
ranging from 93.9-100\% in excluding the LAA, one significant
complication is incomplete exclusion due to residual stump
(\textgreater{} 1 cm) as a result of the clip being deployed too
distally. We describe here the first reported case of implanting a
second clip underneath the first clip to obliterate the residual stump
for a 71-year-old male with AF evaluated for intervention for stroke
risk reduction.%
\end{abstract}%



\sloppy


\textbf{Introduction:}

Epicardial exclusion of LAA has gained increasing popularity since its
introduction in 2009. However, there are single center studies of this
technique for standalone stroke risk reduction in patients with
AF.\textsuperscript{1-3} While the clip has demonstrated a success rate
ranging from 93.9-100\% in excluding the LAA, one significant
complication is incomplete exclusion due to residual stump greater than
1 cm as a result of clip being deployed too
distally.\textsuperscript{1}We describe here a solution to that
complication, which is the first reported case of implanting a second
clip underneath the first clip to obliterate the residual stump.

\textbf{Methods and methods:}

Patient chart was reviewed for complete history and details of his
operative details and postoperative course. The Institutional Review
Board (IRB) approval was not obtained, since single case report with
deidentified data does not require IRB approval. The patient provided
informed written consent for the publication of the study data.

\textbf{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
CHA\textsubscript{2}DS\textsubscript{2}-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 5\textsuperscript{th} and a 12 mm port in the
7\textsuperscript{th}intercostal space in the mid-axillary line and a 5
mm working port in 7\textsuperscript{th} intercostal space anterior to
the anterior axillary line. CO\textsubscript{2} 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 3\textsuperscript{rd} postoperative
day.

\textbf{Discussion:}

Left atrial appendectomy to prevent embolism in patients with rheumatic
heart disease and atrial fibrillation was first reported by Madden in
1949.\textsuperscript{4} In order to prevent embolism in patients with
AF undergoing LAA excision/exclusion, the surgical technique is
important. Years later, in his report of 306 patients who underwent maze
procedure and followed for up to 11.5 years, Dr. Cox reported two early
strokes with an incidence of 0.7\% and only one more stroke in the
follow-up period.\textsuperscript{5} This benefit was ascribed to the
maze procedure restoring sinus rhythm and atrial transport, and
secondarily to obliteration of the LAA.

One of the complications of the clip is ``too distal deployment'' on the
LAA, leaving a residual stump greater than 1 cm. While the 1 cm figure
is an arbitrary number and its impact on future risk of stroke is
undetermined, it remains a considerable obstacle towards a wide
acceptance of this technique in the physician community. To this end, it
is important that implanting surgeon do all they can to make sure the
clip is deployed at the base of the LAA. The LAA may appear obliterated
on the TEE due to external pressure from the delivery system during
deployment of the clip. Once the clip is deployed and the delivery
system disconnected the stump may bounce back outward to show its real
size. It is also important that the appendage be evaluated in multiple
different views to make sure of obliteration. If recognized in the
operating room, such as happened in our case, one can deploy an
open-mouth V-Shaped clip under the previous clip. This is the first such
report of successful use of a second clip to obliterate the residual
stump. Because the Atriclip Pro V is more expensive, we only keep it as
a backup for such situations (because of its higher price) but continue
to use the more economical Atriclip Pro 2 for routine thoracoscopic
clipping. In conclusion, it is important to obliterate the LAA as close
to the base as possible. If there is a residual stump of a significant
size, approaching 1 cm, a second clip can be deployed under the first
clip to obliterate the LAA completely.

\textbf{Conclusion:}

When excluding LAA with an epicardial clip, care must be taken to leave
no residual stump behind before deploying the clip. In case of a
residual stump, a second clip can be applied in select cases, depending
on the anatomy of the LAA.

\textbf{Figure/Video legend:}

Figure 1. Long chicken wing type LAA (diamond), with 45 mm Atriclip Pro
2 (star). TEE shows residual stump of LAA.

Figure 2. Completed exclusion of LAA with two clips: Atriclip Pro V
(Triangle) and Atriclip Pro 2 (Diamond). TEE shows an obliterated
residual stump.

Video 1. Thoracoscopic application of a second Atriclip proximal to the
first clip on the base of LAA.

\textbf{References:}

{[}1{]} Ellis CR, Aznaurov SG, Patel NJ, Williams JR, Sandler KL, Hoff
SJ \emph{et al} . Angiographic Efficacy of the Atriclip Left Atrial
Appendage Exclusion Device Placed by Minimally Invasive Thoracoscopic
Approach. JACC Clin Electrophysiol. 2017 Dec 11;3(12):1356-1365. Epub
2017 May 9. PMID: 29759664.

{[}2{]} Branzoli S, Marini M, Guarracini F, Pederzolli C, Pomarolli C,
D'Onghia G \emph{et al} . Epicardial standalone left atrial appendage
clipping for prevention of ischemic stroke in patients with atrial
fibrillation contraindicated for oral anticaogulation. J Cardiovasc
Electrophysiol. 2020 Aug;31(8):2187-2191. Epub 2020 Jun 17. PMID:
32495408.

{[}3{]} Smith NE, Joseph J, Morgan J, Masroor S. Initial Experience with
Minimally Invasive Surgical Exclusion of the Left Atrial Appendage with
an Epicardial Clip. Innovations (Phila). 2017 Jan/Feb;12(1):28-32. PMID:
28129318.

{[}4{]} Madden JL. Resection of the left auricular appendix; a
prophylaxis for recurrent arterial emboli. J Am Med Assoc. 1949 Jul
2;140(9):769-72. PMID: 18152330.

{[}5{]} Cox JL, Ad N, Palazzo T. Impact of the maze procedure on the
stroke rate in patients with atrial fibrillation. J Thorac Cardiovasc
Surg. 1999 Nov;118(5):833-40. PMID: 10534688.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/2nd-Atrial-Clip---Figure-1/2nd-Atrial-Clip---Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/2nd-Atrial-Clip---Figure-2/2nd-Atrial-Clip---Figure-2}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`2nd Atrial Clip - Video 1.mp4`  available at \url{https://authorea.com/users/316008/articles/548053-management-of-residual-left-atrial-appendage-stump-with-a-second-epicardial-clip}

\selectlanguage{english}
\FloatBarrier
\end{document}

