Stroke prevention in nonvalvular atrial fibrillation: Thoracoscopic left atrial appendage closure with or without surgical ablation

Objectives

Totally thoracoscopic left atrial appendage closure (TT-LAAC) with or without the MAZE procedure is an LAA management technique that prevents cardioembolic events by closing the LAA in patients with atrial fibrillation (AF). Additionally, it facilitates rhythm control with a concurrent a mini-maze procedure. Here we present TT-LAAC outcomes without the MAZE procedure (TT-LAAC) and with the maze procedure (TT-MAZE).

Methods

LAAC and/or bilateral pulmonary vein isolation were performed under complete thoracoscopy, with ablation performed using a radiofrequency device. Patients undergoing both LAAC and ablation were classified as TT-MAZE, whereas those undergoing only closure were classified as TT-LAAC. Successful closure was defined as a stump <10 mm as assessed via intraoperative transesophageal echocardiography.

Results

Between March 2018 and January 2025, 200 patients (155 males, 45 females; mean age, 70.4 ± 9.6 years) underwent TT-MAZE (n = 151) or TT-LAAC (n = 49). AF subtypes included paroxysmal in 62 patients, persistent in 105 patients, and permanent in 33 patients. Closure of the LAA was successful in all patients. No in-hospital mortality was observed. Anticoagulant therapy was discontinued in 96.5% of the patients (n = 193) of patients after 3 months. No postoperative strokes were observed during the mean follow-up of 3 years. In the TT-MAZE group, sinus rhythm was maintained in 72% of patients at 4 years postoperatively.

Conclusions

TT-LAAC procedures effectively prevent cardioembolic stroke even after discontinuation of anticoagulant therapy, regardless of whether sinus rhythm was restored after surgery. These procedures remain a valuable treatment strategy for AF.