Robotic-Assisted Transmyocardial Laser Revascularization Combined With Left Atrial Appendage Exclusion Using an Atrial Clip

Transmyocardial laser revascularization (TMR) is a US FDA-approved intervention utilizing a laser device intended to treat ischemic myocardium. TMR was approved by the FDA in 1998 to treat moderate to severe angina (class 3-4 Canadian Cardiovascular Society classification system) as a result of diffuse coronary disease not amenable to conventional medical therapy, percutaneous coronary intervention, or surgical revascularization. At a mean of five years, 88% of patients who receive TMR experience at least a two level reduction in angina class, compared with 44% of patients managed medically (1). Long-term analysis has shown a reduction in unstable hospitalizations at 43 months of follow-up (2).

Atrial fibrillation is the most common cardiac arrhythmia affecting more than 33 million individuals worldwide (3). Greater than 90% of cardiac emboli in nonvalvular atrial fibrillation originate in the left atrial appendage (LAA) (4). Open and minimally invasive techniques have been employed for surgical LAA occlusion. The current European Society of Cardiology and American Heart Association/American College of Cardiology guidelines suggest that surgical excision/exclusion of the LAA may be considered in patients undergoing cardiac surgery or thoracoscopic atrial fibrillation surgery (grade IIB) (5). The Atriclip and Atriclip Pro (Atricure, West Chester, Ohio) have demonstrated high success rates in the EXCLUDE trial (6). Closure efficacy of the atrial clip applied via total thoracoscopic approach has recently been demonstrated to have a 93.9% closure rate confirmed by angiography (7).

This video demonstrates the technique of robotic-assisted TMR combined with LAA exclusion. The patient was a 73-year-old with a history of CABG x 2 1999. He had medically refractory angina (Class IV) despite enhance external counter pulsation (EECP) and multiple percutaneous interventions. Cardiac catheterization demonstrated patent LIMA-LAD, SVG-PDA, and stents. He underwent robotic-assisted TMR with 20 laser drilling to the anterior-lateral and posterior-lateral walls, focusing on the lateral wall. Concomitantly left atrial appendage exclusion was performed with a 45 mm Pro V AtriCure atrial clip. He was discharged home two days later.

References

1. Allen KB, Dowling RD, Angell WW, Gangahar DM, Fudge TL, Richenbacher W, et al. Transmyocardial revascularization: 5-year follow-up of a prospective, randomized, multicenter trial. Ann Thorac Surg. 2004;77:1228-1234.
2. Aaberge L, Rootwelt K, Blomhoff S, Saatvedt K, Abdelnoor M, Forfang K. Continued symptomatic improvement three to five years after transmyocardial revascularization with CO2 laser: A late clinical follow-up of the Norwegian Randomized trial with transmyocardial revascularization. J Am Coll Cardiol. 2002;39(10):519-524.
3. Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation. 2014; 129:837-847.
4. Blankshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical with atrial fibrillation. Ann Thorac Surg. 1996; 61:755-759.
5. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland Jr JC, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Carediology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130:2071-2104.
6. Ailawadi G, Gerdisch MW, Harvey RL, Hooker RL, Damiano Jr RJ, Salamon T, et al. Exclusion of the left atrial appendage with a novel device: early results of a multicenter trial. J Thorac Cardiovasc Surg. 2011;142:1002-1009.
7. Ellis CR, Aznaurov SG, Patel NJ, Williams JR, Sandler KL, Hoff SJ, et al. Angiographic efficacy of the Atriclip left atrial appendage exclusion device placed by minimally invasive thoracoscopic approach. JACC Clin Electrophysiol. 2017;3:1356-1365.

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