migotanie przedsionkw ( mp ) jest zwizane z dugoterminow wysz miertelnoci i wyszym ryzykiem udaru take u pacjentw kierowanych do chirurgicznej rewaskularyzacji serca .
ze wzgldu na odsetek komplikacji i zaprzestania terapii doustnymi antykoagulantami chirurgiczne zamknicie uszka lewego przedsionka ( ulp ) moe si przyczyni do redukcji ryzyka udaru mzgu w tej populacji .
i praktyczne porwnanie wczesnej skutecznoci oraz bezpieczestwa zastosowania dwch typw epikardialnych okluderw ulp stosowanych u chorych z przetrwaym mp podczas operacji pomostowania ttnic wiecowych bez zastosowania krenia pozaustrojowego .
do badania wczono 15 kolejnych pacjentw z przetrwaym mp , u ktrych podczas poczonej operacji pomostowania ttnic wiecowych i epikardialnej ablacji lewego przedsionka naprzemiennie stosowano dwa typy okluderw ( tigerpaw system ii lub atriclip ) .
w caej badanej populacji stwierdzono podwyszone ryzyko operacyjne ( redni euroscore ii : 3,2  0,3% ) .
u wszystkich pacjentw w grupie atriclip przeprowadzono skuteczne , potwierdzone przezprzeykowym badaniem echokardiograficznym zamknicie ulp .
w okresie wewntrzszpitalnym w badanej grupie nie wystpiy zgon , incydent zakrzepowo - zatorowy , zawa serca ani konieczno reoperacji .
epikardialne zamknicie ulp podczas operacji na ttnicach wiecowych bez zastosowania krenia pozaustrojowego zostao przeprowadzone w sposb prosty , bezpieczny i skuteczny w grupie pilotaowej z zastosowaniem okludera atriclip .
procedura moe by uproszczona dziki doborowi typu zastosowanego okludera do morfologii ulp oraz zakresu przeprowadzanej rewaskularyzacji .
patients with persistent atrial fibrillation ( af ) referred to coronary artery bypass graft are often not considered for concomitant ablation . even after successful coronary revascularisation there is an increased risk of mortality related to af , stroke , and inherent anticoagulation therapeutic complications [ 2 , 3 ] .
long - term safety and effectiveness of surgical epicardial left atrial appendage ( laa ) occlusion has been reported in patients undergoing open - heart procedure .
since epicardial occluding devices seem to result in higher long - term complete occlusion than direct suturing of laa it is necessary to define suitable techniques for patients undergoing off - pump coronary artery bypass grafting ( opcab ) and concomitant anti - arrhythmic procedures .
the study presents the first clinical and practical comparison of device application and intraoperative confirmation of laa occlusion of two surgical epicardial laa occluders ( laao )  atriclip ( atricure , dayton , oh , usa ) and tigerpaw system ii ( maquet )  in a pilot cohort of patients referred for opcab and concomitant epicardial la ablation .
this study included 15 patients with persistent atrial fibrillation and coronary artery disease referred for concomitant surgical therapy .
off - pump technique was used in all patients due to moderately increased risk profile measured by euroscore ( table i ) .
all patients had high stroke risk according to cha2ds2-vasc score ( average yearly risk : 4.7  2.7% ) . in nine patients high risk of bleeding on oral anticoagulation was calculated with has - bled score ( average yearly risk : 6.7  4.1% ) [ 6 , 7 ] .
patients characteristics lvef  left ventricular ejection fraction , mi  myocardial infarction , chf  con - gestive heart failure , te 
thromboembolic event , copd  chronic pulmonary disease , gfr  glomerular filtration rate in all patients transoesophageal echocardiography ( tee ) was performed prior to surgery to assess the laa for presence of thrombus , morphologic type , and orifice diameter .
patients were alternately assigned to tigerpaw ( 8 patients ) or atriclip ( 7 patients ) occluder ( fig . 1 and 2 ) .
after harvesting of grafts , via median sternotomy , the patient was given 300 units per kilogram of heparin and pulmonary vein isolation was completed with use of a bipolar radiofrequency probe . in 10 patients with cardiomyopathy the right pleural cavity was opened to allow stable haemodynamics during laa exposure .
the laao was applied and the heart was returned to the anatomic position to assess laa occlusion with tee ( fig .
atriclip device is deployed longitudinal to left atrial appendage ( laa ) orifice and parallel to circumflex coronary artery tigerpaw system ii application is perpendicular to circumflex artery pre- and postoperative transoesophageal echocardiography ( tee ) showing complete left atrial appendage ( laa ) occlusion in all patients single or double antiplatelet therapy was prescribed depending on the patient 's history of previously performed percutaneous coronary intervention .
primary endpoints consisted of uncomplicated laao implantation , complete laa occlusion confirmed by intraoperative tee including flow absence in laa , and remnant stump less than 1 cm long and without the need of conversion to extracorporeal circulatory support ( ecc ) .
secondary end points consisted of freedom from te event , bleeding , or tamponade requiring surgical intervention .
this study included 15 patients with persistent atrial fibrillation and coronary artery disease referred for concomitant surgical therapy .
off - pump technique was used in all patients due to moderately increased risk profile measured by euroscore ( table i ) .
all patients had high stroke risk according to cha2ds2-vasc score ( average yearly risk : 4.7  2.7% ) . in nine patients high risk of bleeding on oral anticoagulation was calculated with has - bled score ( average yearly risk : 6.7  4.1% ) [ 6 , 7 ] .
patients characteristics lvef  left ventricular ejection fraction , mi  myocardial infarction , chf  con - gestive heart failure , te 
in all patients transoesophageal echocardiography ( tee ) was performed prior to surgery to assess the laa for presence of thrombus , morphologic type , and orifice diameter .
patients were alternately assigned to tigerpaw ( 8 patients ) or atriclip ( 7 patients ) occluder ( fig . 1 and 2 ) .
after harvesting of grafts , via median sternotomy , the patient was given 300 units per kilogram of heparin and pulmonary vein isolation was completed with use of a bipolar radiofrequency probe . in 10 patients with cardiomyopathy the right pleural cavity was opened to allow stable haemodynamics during laa exposure .
the laao was applied and the heart was returned to the anatomic position to assess laa occlusion with tee ( fig .
atriclip device is deployed longitudinal to left atrial appendage ( laa ) orifice and parallel to circumflex coronary artery tigerpaw system ii application is perpendicular to circumflex artery pre- and postoperative transoesophageal echocardiography ( tee ) showing complete left atrial appendage ( laa ) occlusion
in all patients single or double antiplatelet therapy was prescribed depending on the patient 's history of previously performed percutaneous coronary intervention . according to the protocol , oac was not administered .
primary endpoints consisted of uncomplicated laao implantation , complete laa occlusion confirmed by intraoperative tee including flow absence in laa , and remnant stump less than 1 cm long and without the need of conversion to extracorporeal circulatory support ( ecc ) .
secondary end points consisted of freedom from te event , bleeding , or tamponade requiring surgical intervention .
preoperative tee revealed three different laa morphologic types : wind sock ( six patients ) , broccoli ( six patients ) , and chicken wing ( three patients ) .
the wind sock type occurred in four patients , broccoli in three patients , and chicken wing in one patient . in the atriclip group
the wind sock type was found in two patients , broccoli in three patients , and chicken wing in two patients .
there was no significant difference in laa orifice diameter between the tigerpaw ( 18  5 mm ) and atriclip group ( 22  10 mm ; p = 0.3 ) .
the length of laa did not differ significantly between the tigerpaw ( 26  5 mm ) and atriclip group ( 30  5 mm ; p = 0.2 ) . in the actriclip group
all patients gained both primary and secondary endpoints . in the tigerpaw group six of eight patients ( 75% )
the tigerpaw application was complicated . in the first case distal clinches of the device were not tightly locked .
intraoperative transoesophageal echocardiography showed complete occlusion and no flow in laa ; however , the patient was postoperatively checked with computed tomography .
one proximal and one distal clinch perforated the laa tissue but did not lock which resulted in slight bleeding .
computed tomographic study of incomplete left atrial appendage ( laa ) occlusion with tigerpaw system ii device no major adverse event : death , stroke or tia ( transient ischaemic attack ) , myocardial infarction , reoperation , or revascularisation , occurred in either group .
there was no difference in hospital length of stay between the tigerpaw ( 9  1 days ) and atriclip groups ( 13  5 days ; p = 0.07 ) .
implantation of the tigerpaw system was generally quicker ( range = 15 - 30 seconds ) .
tigerpaw positioning is easier since it is an open structure clip , which is applied on the laa base perpendicular to the circumflex artery .
complications with proper tigerpaw application result during clinche fixation on flexible silicon strips . during clenching of laa tissue with the device
the atriclip occluder requires slipping the entirety of the laa tissue through it , parallel to the circumflex artery , which we found more difficult and slightly more time consuming , especially in the broccoli and multi - lobar small laa types ( range = 30 - 60 seconds ) .
the latter also requires the use of both hands , and in the majority of these cases , an additional heart positioner must be used . in 11 patients
an apical heart positioner was utilised : in four patients in the tigerpaw group and six patients in the atriclip group .
conversely , we found it possible to apply the tigerpaw system using only one hand , which resulted in minimal haemodynamic compromise during application .
importantly , the atriclip is stiffer and must be oriented so there is no compromise of the coronary arteries , pulmonary artery , or free wall of the left ventricle , as opposed to the tigerpaw , which is constructed from a flexible silicone fabric .
these factors necessitate a more accurate size selection of atriclip . in the atriclip group ,
smaller sized occluders were generally needed in the tigerpaw group ( 35 mm in five cases , 45 mm in two , and 55 mm in one patient ) .
notably , during positioning of the tigerpaw , the surgeon must avoid grasping the posterior pericardial tissue located directly beneath the appendage . using the atriclip system one can reposition the device before final release of the clip .
this is not possible with tigerpaw because the metal clinches perforate the laa tissue with the clip closure .
implantation of the tigerpaw system was generally quicker ( range = 15 - 30 seconds ) .
tigerpaw positioning is easier since it is an open structure clip , which is applied on the laa base perpendicular to the circumflex artery .
complications with proper tigerpaw application result during clinche fixation on flexible silicon strips . during clenching of laa tissue with the device
these strips may bend . consequently , both parts of clinches interdigitate properly and remain unlocked .
the atriclip occluder requires slipping the entirety of the laa tissue through it , parallel to the circumflex artery , which we found more difficult and slightly more time consuming , especially in the broccoli and multi - lobar small laa types ( range = 30 - 60 seconds ) .
the latter also requires the use of both hands , and in the majority of these cases , an additional heart positioner must be used . in 11 patients
an apical heart positioner was utilised : in four patients in the tigerpaw group and six patients in the atriclip group .
conversely , we found it possible to apply the tigerpaw system using only one hand , which resulted in minimal haemodynamic compromise during application .
importantly , the atriclip is stiffer and must be oriented so there is no compromise of the coronary arteries , pulmonary artery , or free wall of the left ventricle , as opposed to the tigerpaw , which is constructed from a flexible silicone fabric .
these factors necessitate a more accurate size selection of atriclip . in the atriclip group ,
smaller sized occluders were generally needed in the tigerpaw group ( 35 mm in five cases , 45 mm in two , and 55 mm in one patient ) .
notably , during positioning of the tigerpaw , the surgeon must avoid grasping the posterior pericardial tissue located directly beneath the appendage . using the atriclip system one can reposition the device before final release of the clip .
this is not possible with tigerpaw because the metal clinches perforate the laa tissue with the clip closure .
surgical treatment of af is highly effective over the long - term , when using a cox - maze lesion set .
thus , there is a growing trend to perform surgical ablation as a concomitant procedure with other open surgery to improve long - term outcomes . as in this series , most patients with persistent af and advanced coronary artery disease have an increased surgical risk due to heart failure and concomitant co - existing morbidity . since laa is the source of thrombus in 90% of patients with nonvalvular af , patients with af who require cabg are appropriate candidates for pulmonary vein ablation and epicardial laa occlusion . in patients who undergo cabg without ablation or
in whom surgical ablation is not effective and laa is left open , standard stroke prevention is based on oral anticoagulation ( oac ) therapy .
however , the incidence of anticoagulant - related bleeding leads to discontinuation of therapy in up to 30% of patients after one year and in 80% of patients after six years .
new oacs ( noacs ) are discontinued in 21% of patients during the first year , can not be used in patients with renal failure , and cause increased bleeding risk most commonly from the gastrointestinal tract .
european society of cardiology guidelines recommend oac administration driven by cha2ds2-vasc and has - bled scores . in this experience ,
data from that pilot population indicate that off - pump epicardial laa occlusion can be done safely with an atriclip device .
. however , tigerpaw implantation seems to be easier and may play a role in the future with minimally invasive or thoracoscopic procedures .
closed clip ( atriclip ) use requires slipping laa tissue through the device so an additional positioning tool is necessary .
however , the tigerpaw device seems to be more convenient to occlude smaller , multilobar (  broccoli  ) laa types .
it should be noted that the presence this morphologic broccoli type laa is related to an additionally increased risk of stroke .
a double suture technique reduces incomplete occlusion to 10.3% when applied from an endocardial approach .
stapling has been reported to leave up to 28% of laa stumps only partially occluded .
the transcatheter watchman device has been shown to result in significant peri - device flow in 32% of patients , and in 50% of those , laa thrombi were noted in the 22% that had tee [ 18 , 19 ] .
epicardial application may be safely done during off - pump surgery since it can be accomplished quickly and results in no haemodynamic compromise .
further study will reveal whether different application angles of tigerpaw and atriclip affects the remnant laa stump area . in spite of the tigerpaw no longer being clinically available
, these data may be applicable to future iterations . in patients assigned to the atriclip group use of an apical heart positioner
it is also technically feasible to position the beating heart using deep pericardial sutures or a tissue stabiliser to gain adequate exposure of the laa for occluder application .
we found , however , that in patients with persistent af and depressed left ventricular function use of an apical positioner maintained adequate haemodynamics .
further study is necessary to determine if prophylactic epicardial laa closure concomitant with cabg procedures will reduce the incidence of long - term atrial fibrillation and stroke .
in an initial cohort epicardial laac during off - pump cabg in patients with persistent af was performed easily , safely , and successfully with atriclip devices .
. it might be useful to adapt the use of the type of occluding device to the laa morphologic type and target revascularisation vessels to avoid the additional use of a heart positioner or obviate coronary compression .
 introductionatrial fibrillation ( af ) increases long - term mortality and stroke rate in patients having coronary artery bypass grafting ( cabg ) . 
 because oral anticoagulation ( oac ) is associated with both a significant incidence of discontinuation and well known complication rates , left atrial appendage occlusion might be beneficial for stroke prevention . 
 this study presents the first clinical and practical comparison of two epicardial left appendage occluders ( laao ) accruing experience in application during off - pump coronary revascularisation in patients with persistent af.material and methodsfifteen consecutive patients with persistent af were assigned to intraoperative laa occlusion with either tigerpaw system ii ( n = 8) or atriclip ( n = 7 ) device during off - pump cabg and concomitant left atrial epicardial ablation . 
 both systems were analysed in terms of ease and safety of application along with intraoperative laa occlusion success.resultssurgical risk was increased in the study population ( mean euroscore ii : 3.2  0.3% ) . in all patients in the atriclip group 
 successful off - pump laa occlusion confirmed by intraoperative transoesophageal echocardiography was achieved . 
 the tigerpaw application was quicker and easier , but in 2 patients it was unsuccessful . during the hospital 
 stay there were no bleeding or thromboembolic events recorded.conclusionsin a pilot cohort epicardial laao during off - pump cabg in patients with persistent af was performed safely and successfully with an atriclip device . 
 the tigerpaw system requires technological improvement 
 . it might be useful to adapt the use of the type of occluding device to the laa morphologic type and target revascularisation vessels to avoid the additional use of a heart positioner or obviate coronary compression . 
Wstp
Materia i metody
Wyniki
Wnioski
Introduction
Material and methods
Study population
Surgical procedure
Postoperative protocol
Study endpoints
Results
Practical considerations aspects
Discussion
Conclusions
Disclosure