Surgical implant of Medtronic Penditure left atrial appendage exclusion clip during off-pump bilateral internal thoracic artery coronary artery bypass grafting
Clinical vignette
A 52-year-old man presented to the emergency department with severe chest pain (10/10) that occurred during sleep. He had a significant family history of coronary artery disease, along with hypertension, hyperlipidemia, pre-diabetes (HbA1c 6.4%), and frequent palpitations. The diagnosis of non-ST elevated myocardial infarction (NSTEMI) was established with a high-sensitivity troponin I (hsTnI) level of 7,037 ng/mL. Additionally, he experienced a brief episode of atrial fibrillation (AF) lasting less than 20 minutes, which converted to normal sinus rhythm after an intravenous amiodarone bolus. Left heart catheterization via the left radial artery revealed a critical 90% stenosis in the proximal left anterior descending (LAD) artery, 90% stenosis in obtuse marginal 1 (OM1), and chronic total occlusion (CTO) of the mid right coronary artery. Subsequently, the patient underwent an off-pump coronary artery bypass graft (CABG) procedure involving left internal thoracic artery (ITA) to LAD anastomosis, right ITA (RITA) in situ via the transverse sinus to OM1, saphenous vein graft from the aorta to posterior descending artery (PDA), and left atrial appendage (LAA) exclusion with a Penditure clip (Medtronic, Inc., Minneapolis, MN, USA).
Surgical techniques
Preparation
Transesophageal echocardiography (TEE) confirmed the absence of thrombi in the LAA. The Penditure LAA exclusion system clip, designed for permanent implantation, is intended to be placed at the base of the LAA. Before clip positioning, measurement of the LAA base should be performed using the included sizer. The clip is available in four sizes: 35, 40, 45, and 50 mm.
Operation
For clip placement, the LAA was gently mobilized with an atraumatic forceps. The fabric-free design and low clip profile provided an advantage in the presence of an in situ RITA passing via the transverse sinus to reach OM1. The wide opening at the base of the Penditure clip offered good visibility during deployment, and the tip-first closure ensured complete and secure exclusion of the LAA. The clip, being recapturable and redeployable after the first deployment, provided flexibility during placement. In this patient’s case, the RITA to OM1 anastomosis was performed after clip placement to avoid possible graft capture and obstruction.
Completion
After the clip was released, TEE was utilized to verify complete exclusion, enabling the assessment of any residual stump that may necessitate a more proximal repositioning of the device. The Medtronic Penditure clip presents two small pins at the tip of the handle to recapture, reposition and redeploy the device itself if needed.
Comments
Clinical results
Intraoperative graft flow was assessed with transient time-flow measurement, demonstrating excellent revascularization outcomes. Postoperatively, no stroke or myocardial infarction occurred.
Indications
The recently released 2023 American College of Cardiology/American Heart Association (ACC/AHA) guidelines (1) have upgraded surgical LAA exclusion to class I for patients with AF undergoing cardiac surgery and having a CHA2DS2-VASc score of ≥2 or an equivalent stroke risk. This, along with the continuation of anticoagulation therapy, is indicated to lower the risk of stroke and systemic embolism.
Advantages
The LAA clip device presents several key features to enhance its functionality and adaptability. Equipped with a rotation knob allowing a ±90° rotation, the device incorporates an 11 cm bendable and rotatable aluminum shaft for precise maneuverability (2). The implantable atraumatic clip, designed with a slight curve to align with atrial anatomy, provides the deployment tool a total of 16.8 cm working length. The clip’s fabric-free design reduces the chances of inflammation and adhesions with adjacent tissue. Notably, the recapturable and redeployable clip feature, offers flexibility during the placement process. The Penditure clip includes an actuation lever for efficient opening and a release trigger for single-button deployment without the need for string cutting. The clip utilizes a closure mechanism initiated from the tip, ensuring thorough capture and preventing any risk of tissue moving forward. Other clipping devices have evolved from the original closed-ended tip to the newer open-ended V-clips (3). Both types demonstrate similar performance, and the selection between them depends solely on the surgeon’s preference.
Acknowledgments
Funding: None.
Footnote
Conflicts of Interest: G.T.: Consulting fee for Peters Surgical. The other authors have no conflicts of interest to declare.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024;149:e1-e156. Erratum in: Circulation 2024;149:e167 Circulation 2024;149:e936. [Crossref] [PubMed]
- Medtronic. Penditure LAA - Left Atrial Appendage Exclusion Systems n.d. (accessed January 13, 2024). Available online: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/left-atrial-appendage-exclusion-systems/penditure-laa.html
- Lee RJ, Hanke T. The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture). Card Electrophysiol Clin 2023;15:201-13.
