Discussion:
Left atrial appendectomy to prevent embolism in patients with rheumatic heart disease and atrial fibrillation was first reported by Madden in 1949.4 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.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.