Current evidence on the safety and efficacy of thoracoscopic exclusion of the left atrial appendage (LAA) for non-valvular atrial fibrillation (AF) for the prevention of thromboembolism as an adjunctive procedure to surgical ablative techniques is inadequate in quantity and quality. Therefore, this procedure should only be used as an adjunct to surgical ablation with special arrangements for clinical governance, consent and audit or research.
Clinicians wishing to undertake thoracoscopic exclusion of the LAA for non-valvular AF for the prevention of thromboembolism as an adjunct to surgical ablation should take the following actions.
Inform the clinical governance leads in their Trusts.
Ensure that patients and their carers understand the uncertainty about the procedure's safety and efficacy, and provide them with clear written information. In addition, the use of NICE's information for the public is recommended.
Audit and review clinical outcomes of all patients having thoracoscopic exclusion of the LAA for non-valvular AF for the prevention of thromboembolism as an adjunctive procedure to ablative techniques (see section 3.1).
Current evidence on the safety and efficacy of thoracoscopic exclusion of the LAA for non-valvular AF for the prevention of thromboembolism when used in isolation is inadequate. Therefore, this procedure should only be used in the context of research. Research studies should clearly define patient selection. They should report the cardiac rhythm achieved after surgery and also adverse events, particularly stroke and death, in both the short and longer term.
Patient selection should be carried out by a multidisciplinary team including a cardiac surgeon and other clinicians experienced in the management of patients with AF who are at risk of stroke. Patients should be considered for alternative treatments to reduce the risk of thromboembolism associated with AF, and should be informed about these alternatives.
This procedure should be carried out only by cardiac surgeons with experience in thoracoscopic surgery and specific training in the procedure.