Robotic Left Atrial Appendage Occlusion

This case describes a robotic left atrial appendage occlusion (LAAO) performed at a specialized institution that receives patients who are poor candidates for percutaneous left atrial appendage (LAA) devices. These include individuals with contraindications to oral anticoagulation (OAC) therapy commonly due to active gastrointestinal bleeding or patients with failed previous device attempts. The robotic LAAO may be performed in conjunction with robotic coronary artery bypass grafting (CABG) or as a standalone procedure. 

This specific case involved an 84-year-old male with long-standing persistent atrial fibrillation (AF), polycythemia vera, and recurrent GI bleeds. He was referred after an unsuccessful previous attempt with a percutaneous device. The procedure began with the patient in a supine position, with the left hemithorax slightly elevated to improve surgical access. A Texas condom catheter was used instead of a Foley catheter. 

Three robotic ports were placed along the midclavicular line at the second, fourth, and sixth intercostal spaces. Before docking the robotic system, a cryo nerve block was administered for pain control by applying cryoablation at negative 65-degrees Celsius for 90 seconds. Following robotic docking and optimal port positioning, the pericardium was opened near the inferior phrenic nerve and extended cranially to expose the pulmonary artery reflection. 

A fourth, 12 mm working port was placed at the midaxillary line for device delivery. The port’s stable intrathoracic pressure and valveless design made it ideal for this step. A 4-0 polypropylene traction suture was used to elevate the pericardium and improve visibility. Two soft pads protected the LAA during manipulation, and adhesions were carefully removed. 

Using the device kit, the LAA stump was measured at 45 mm. The selected device featured a compact profile and enhanced visibility in minimally invasive surgeries. The clip was inserted, and the LAA was positioned using soft pads and robotic graspers. 

Transesophageal echocardiography (TEE) was crucial throughout, guiding placement and ensuring no compromise to surrounding structures like the circumflex artery. Once optimal clip positioning was confirmed via TEE, the clip was released. Intraoperative imaging showed complete exclusion of the LAA with no residual leak. 

The procedure concluded with fluid drainage, chest tube placement, and lung reexpansion. Total operative time was approximately 40–45 minutes, demonstrating the feasibility and precision of robotic LAAO in specialized centers.   

References

1. Clifton T P Lewis, Richard L Stephens, Vernon D Horst, Margaret Angelillo, Charles M Tyndal. Application of an Epicardial Left Atrial Appendage Occlusion Device by a Robotic-Assisted, Right Chest Approach. Ann Thorac Surg. 2016 May;101(5):e177-8. doi: 10.1016/j.athoracsur.2015.11.028.
2. Alison F Ward, Robert M Applebaum, Nana Toyoda, Ans Fakiha, Peter J Neuburger, Jennie Ngai, Robert G Nampiaparampil, David W Yaffee, Didier F Loulmet, Eugene A Grossi. Totally Endoscopic Robotic Left Atrial Appendage Closure Demonstrates High Success Rate. Innovations (Phila). 2017 Jan/Feb;12(1):46-49. doi: 10.1097/IMI.0000000000000330.

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