Total Robotic-Assisted Pulmonary Resection with Concomitant Left Atrial Appendage Exclusion

Pulmonary malignancies represent one of the most common neoplasms and cancer related deaths worldwide. As patients may present with a history of atrial fibrillation (AF) and a contraindication to anticoagulation, resection of left-sided pulmonary cancers presents a unique opportunity to address the sequelae of the underlying arrhythmia simultaneously. The accompanying video demonstrates placement of an epicardial left atrial appendage (LAA) occlusion device after parenchymal resection.

Case
A seventy-five-year-old man, former smoker with a history of chronic AF, underwent robotic-assisted left upper lobe trisegmentectomy for an apical squamous cell carcinoma. He had a history of a spontaneous subdural hematoma in the setting of warfarin use. His CHA2DS2-VASc score was 6 (adjusted stroke risk per year approximately 9.8 percent), HAS-BLED score was 3 (5.8 percent risk of major bleeding), and ATRIA bleeding risk score was 4 (2.6 percent annual risk of hemorrhage).(1–3)

Technique
A flexible bronchoscopy was performed after double lumen endotracheal tube placement. A transesophageal echocardiogram (TEE) probe was used to ensure absence of LAA thrombus. We used a da Vinci Xi robot and a five-port technique like those described elsewhere.(4) Our approach includes an eighth interspace 15mm utility/accessory port in the anterior axillary line for specimen extraction and LAA exclusion device access.

After parenchymal resection, the pericardium was opened in the midventricular aspect posterior to the phrenic nerve. This incision was continued superiorly toward the pulmonary artery parallel to the phrenic nerve using bipolar cautery to limit the potential thermal spread to the phrenic nerve. A sizing guide was used to approximate the base of the left atrial appendage. An AtriClip PRO-2 model was placed around the LAA and positioned about its base. A test occlusion confirmed minimal residual stump and no blood flow via TEE. The patient was monitored briefly for any hemodynamic fluctuations or electrocardiography changes. The clip was then released and TEE confirmed a 1mm base. The pericardiotomy was not closed. A flexible chest drain was placed and directed medially, adjacent to the pericardiotomy.

Discussion
LAA ligation using an epicardial clip has been described during thoracoscopic resection of lung cancer and in a standalone robotic-assisted setting.(5–7) Like the above-mentioned reports, in their standalone thoracoscopic ligation cases the authors of this article use a fourth or fifth interspace port for placement of the clip device. In standalone LAA ligation procedures, the authors routinely perform either a three-port or single-incision thoracoscopic technique.(8) However, the authors’ technique during robotic-assisted pulmonary resection differs from the above, as the port used for the clip is at a more inferior intercostal level. Despite the port’s inferior position, the current generation AtriClip facilitates placement via multiaxial articulation, thus avoiding the need for enlargement of an existing site or an additional port. To the authors’ knowledge, this is the first report demonstrating LAA ligation during pulmonary resection using a totally robotic technique.

Complete resection of early-stage pulmonary malignancies can yield five-year survival rates of 60 percent and greater. However, the ongoing risks of cardioembolic events and bleeding complications persist in patients with AF after resection. Especially for patients with a contraindication to anticoagulation, exclusion of the LAA can provide risk reduction in ischemic and hemorrhagic events.(9–11)

Reports have noted patients with pulmonary malignancies and concomitant AF are observed in 4–12 percent of cases, and this is likely to grow, given the expected rise of AF over next few decades.(12–14) As such, surgeons may be faced with a greater number of patients with pulmonary neoplasms and AF. Consequently, robotic-assisted left-sided pulmonary resection provides an opportunity to address not only the malignancy but also the complications of AF and oral anticoagulation. The authors encourage the application of concomitant LAA ligation for patients with AF and a contraindication to anticoagulation during uncomplicated left-sided pulmonary resection. The combined approach spares the patient from an additional procedure and general anesthetic while adding minimal time to the case duration.

References

1. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on Atrial Fibrillation. Chest. 2010; 137(2): 263-72.
2. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A Novel User-Friendly Score (Has-Bled) to Assess 1-year Risk of Major Bleeding in Patient With Atrial Fibrillation: The Euro Heart Survey. Chest. 2010; 138(5): 1093-1100.
3. Fang MC, Go AS, Chang Y, et al. A New Risk Scheme to Predict Warfarin-Associated Hemorrhage: The ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011; 58(4): 395-401.
4. Wei B, Cerfolio RJ. Robotic Lobectomy: Left Upper Lobectomy. Oper Tech Thorac Cardiovasc Surg. 2016; 21(3): 230-248.
5. Toale C, Jones J, Fitzmaurice GJ, Eaton D. Left Atrial Appendage Clipping as an Adjunctive Therapy in Lung Cancer Surgery for Patients with Atrial Fibrillation: A Case Report. J Surg Case Rep, 2019; 11:1-3.
6. Mokracek A, Kurfirst V, Csanady J, Hytych V. Combined Surgical Treatment of Lung Cancer and Atrial Fibrillation – First Experience. Clin Surg. 2021; 6:3040-3041.
7. Jett GK, Leal A. Robotic-Assisted Left Atrial Appendage Exclusion with the PRO-V AtriCure Atrial Clip. July 2020. DOI: 10.25373/ctsnet.12723869.
8. DeBoard ZM. Single-Incision Thoracoscopic Left Atrial Appendage Ligation: First Reported Experience. Innovations. 2021; 16(5): 477-479.
9. Toale C, Fitzmaurice GJ, Eaton D, Lyne J, Redmond KC. Outcomes of Left Atrial Appendage Occlusion Using the AtrClip Device: A Systematic Review. Interact Cardiovasc Thorac Surg. 2019; 29(5):655-662.
10. Branzoli S, Marini M, Guarracini F, Pederzolli C, Polarolli C, D’Onghia G, et al. Epicardial Standalone Left Atrial Appendage Clipping for Prevention of Ischemic Stroke in Patients with Atrial Fibrillation Contraindicated for Oral Anticoagulation. J Cardiovasc Electrophysiol. 2020; 31(8):2187-2191.
11. Van Laar C, Verberkmoes NJ, Van Es HW, Lewalter T, Dunnington G, Stark S, et al. Thoracoscopic Left Atrial Appendage Clipping: A Multicenter Cohort Analysis. JACC Clin Electrophysiol. 2018; 4(7): 893-901.
12. Bandyopadhyay D, Ball S, Hajra A, Chakraborty S, Dey AK, Ghosh RK, et al. Impact of Atrial Fibrillation in Patients with Lung Cancer: Insights from National Inpatient Sample. Int J Cardiol Heart Vasc. 2019; 29: 216-217.
13. Jakobsen CB, Lamberts M, Carlson N, Lock-Hansen M, Torp-Pedersen C, Gislason GH, et al. Incidence of Atrial Fibrillation IN Difference Major Cancer Subtypes: A Nationwide Population-based 12 year Follow up Study. BMC Cancer. 2019; 19: 1105.
14. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of Diagnosed Atrial Fibrillation in Adults: National Implications for Rhythm Management and Stroke Prevention: The Anticoagulation Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001; 285(18): 2370-2375.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.