Short-term Follow-up After Epicardial Left Atrial Appendage Clip Occlusion Via

The Anterior Pathway During Minimally-invasiv Cardiac – “Nordpass Maneuver”

OBJECTIVES: Epicardial left atrial appendage occlusion (LAAO) through the transverse sinus using a clip placement can pose technical challenges in minimally invasive cardiac surgery via a right anterolateral minithoracotomy (MICS). This case series aimed to assess the short-term safety outcomes of a new endoscopic anterior pathway for epicardial LAAO during MICS, known as the "Nordpass."

METHOD: All patients undergoing MICS with concomitant LAAO utilizing an epicardial clip device (AtriClip Pro 1 or 2, AtriCure, Dayton, OH, USA) were included between January 2022 and May 2024. Perioperative data were collected retrospectively and analyzed.

RESULTS: This case series comprised 36 patients (median age: 63, interquartile range (IQR); 57, 709), with 17 of them being male. Preoperative left ventricular function was 58% (IQR: 50, 60), and EuroScore II was 1.8% (IQR: 1.1, 2.9). 

All patients underwent echo-guided LAAO clip placement on the beating heart under cardiopulmonary bypass support. The "Nordpass" technique was successfully applied in 35 out of 36 patients.

In addition to LAAO, mitral valve reconstruction was performed in 26 patients, mitral valve replacement in 5 patients, and tricuspid valve reconstruction or replacement in 7 patients (two isolated cases and five in combination with other procedures), with 21 patients receiving additional cryoablation. One patient each underwent tricuspid valve replacement, removal of right atrial thrombus, and atrial septal defect (ASD) occluder removal with ASD patch closure as reoperation. Two patients had endocarditis as their primary diagnosis.

Intraoperative transesophageal echocardiographic monitoring demonstrated successful LAA closure in all cases where a clip was applied. There were no conversions to sternotomy, no reoperations due to bleeding, one postoperative stroke, no myocardial infarctions, and no in-hospital deaths. The average length of hospital stay was 10 days (IQR: 8, 16), with one patient passing away during follow-up.

Table 1 – 3 presents the perioperative.

Conclusion: These findings suggest that the anterior endoscopic pathway may represent a safe and effective technique for epicardial LAAO during MICS via a right anterolateral mini-thoracotomy.