Laqueation of a Giant Aneurysm of the Left Atrial Appendage Using VATS Approach

This video demonstrates the laqueation of a giant aneurysm of the left atrial appendage using a left video-assisted thoracoscopic (VATS) approach.

The patient was an asymptomatic 45-year-old woman with an unremarkable medical history, who was scheduled for percutaneous pulmonary vein isolation due to paroxysmal atrial fibrillation. When she underwent routine computed tomography imaging, a giant 40 x 60 mm left atrial appendage aneurysm (LAAA) was revealed. The percutaneous bilateral pulmonary vein radiofrequency isolation was performed successfully. Postablative transthoracic echocardiography confirmed the aneurysm of the left atrial appendage, no valvular pathology, normal biventricular function, and no thrombus in the aneurysm or in the left atrium. Even though the ablation was successful, taking into consideration potential risk of thromboembolic events, the authors opted for surgical resection of the aneurysm and left atrial appendage.

The procedure was performed minimally invasively using a left VATS approach without cardiopulmonary bypass. After right lung ventilation was initiated, two incisions were made: a 2 cm incision in the left midaxillary line through the fourth intercostal space, and a 1 cm incision for the camera. Some small pleural adhesions were dissected. The pericardium was opened parallel and 2 cm posterior to the left phrenic nerve. The aneurysm of the left atrial appendage was identified. After careful positioning of the articulating endoscopic stapler at the base of the left atrial appendage, the entire structure including the aneurysm was removed with the use of two staplers. There was no bleeding at the staple line. The incision was closed after positioning a thoracic tube.

Macroscopically, a mass measuring 40 x 60 mm was resected, and the histologic analysis showed normal left atrial appendage tissue with minor fibrosis. Intraoperative transesophageal echocardiography confirmed complete removal of the left atrial appendage without any left atrial thrombus or wall motion abnormalities. The patient’s postoperative course was uneventful, and she was discharged on postoperative day four. Four weeks later, she was still in sinus rhythm and showed good recovery.

This case demonstrates that a giant LAAA can be easily, safely, and successfully resected by a totally endoscopic minimally invasive approach through left VATS. This technique will facilitate the surgical management of such a rare disorder, representing an alternative for the treatment of LAAA and thus avoiding large surgical incisions and cardiopulmonary bypass.

Additional Resources

1. Wang H-Q, Zhang Z, Yang H, et al. A huge congenital left atrial appendage aneurysm. Chin Med J (Engl). 2017;130(24):3011-3012.
2. Kiaii B, Doll N, Kuehl M, Mohr FW. Minimal invasive endoscopic resection of a giant left atrial appendage aneurysm. Ann Thorac Surg. 2004;77(4):1437-1438.
3. Ruttkay T, Scheid M, Götte J, Doll N. Endoscopic resection of a giant left atrial appendage. Innovations (Phila). 2015;10(4):282-284.
4. Morin J, Cantin L, Pasian S, Philippon F, Beaudoin J. Giant left atrial appendage aneurysm mimicking mediastinal mass and associated with incessant atrial arrhythmias. J Atr Fibrillation. 2017;9(6):1539.
5. Kuiten WMM, de Heer LM, van Aarnhem EEHL, Onsea K, van Herwerden LA. Giant left atrial appendage: a rare anomaly. Ann Thorac Surg. 2013;96(4):1478-1480.