Left atrial appendage ligation with single transthoracic port assistance: a study of survival assessment in a porcine model (with videos)

Background: Left atrial appendage (LAA) exclusion is a well-known procedure for the prevention of stroke in high-risk patients with atrial Fibrillation and contraindication to long-term oral anticoagulant therapy. Objective: To evaluate a natural orifice transluminal endoscopic surgery (NOTES) approach for LAA ligation. Design: In 4 acute and 6 survival pigs, we performed LAA by using a forward-viewing, single-channel gastroscope and an operative thoracoscope with a 3-mm working channel (introduced through an 8-mm single transthoracic port). Setting: Animal laboratory. Interventions: The gastroscope was introduced in the thoracic cavity through an esophageal submucosal tunnel. An end loop introduced through the gastroscope was used to legate the LAA. In the survival experiments, the esophageal mucosa was closed using hemoclips. Main Outcome Measurements: The time, safety, and feasibility of the procedure were recorded. In the survival experiments, endoscopy and postmortem examination were performed on postoperative day 14. Results: Creation of a submucosal tunnel and esophagotomy were safely performed in all animals without incidents. The mean time for esophagotomy was 17.0 +/- 6.3 minutes. Pericardial dissection and LAA ligation were pet-foal-led in all animals but 1. The mean time for LAA ligation was 34.4 +/- 19.1 minutes. No adverse events occurred during the survival period. Endoscopy showed complete esophageal closure. Postmortem examination revealed pleural adhesions on the site of pericardial dissection, and the LAA was fibrotic: with the endoloop in place. Limitations: Animal study. Conclusions: LAA ligation with single transthoracic trocar assistance is feasible and may be an alternative to anticoagulant therapy or to permanent intracardiac implants in patients with atrial fibrillation. (Gastrointest Endosc 2012;75:1055-61.)