It’s the Destination, Not the Journey: Surgical Deployment of Percutaneous Devices

Abstract

For transcatheter structural heart technologies to be successful, they must meet thresholds of efficacy and durability, with low complication rates as well as deliverability via either the venous or arterial system, thus significantly limiting device size. The mode of action of these percutaneous devices can be refined iterations of surgical devices (transcatheter aortic valve replacement), can mimick surgical techniques (the MitraClip replicating the Alfieri stitch), or can be developed to achieve the same result via a different mechanism (preventing access to the left atrial appendage (LAA) using occlusive devices (occlusion vs suturing or ligation)). Many percutaneous devices have features that can be valuable in an open procedure beyond traditional surgical techniques. The ability for procedural optimization with direct visualization and access to the device is a unique potential benefit for the surgeon to exploit. The research correspondence, Intraoperative Left Atrial Appendage Occluder Implantation with the Amplatzer Cardiac Plug, describes using a percutaneous left atrial occlusion device in an open surgical procedure. The authors demonstrate the ease of use (implantation within less than 3 minutes), and unobstructed visualization assuring ideal location and seal of the device at the time of the procedure. At six months, oral anticoagulation was discontinued in all patients after transesophageal echocardiography assessment, and no device-related thrombus was noted. At first glance, the rationale to use a transcatheter LAA closure device during open heart surgery is not entirely clear and may seem counterintuitive. Nevertheless, there are several theoretical reasons that a transcatheter device may be preferable over surgical closure. First, data regarding the clinical efficacy (stroke prevention) of surgical closure is limited, while percutaneous device closure has been shown to be effective in clinical randomized trials. Second, traditional surgical techniques have a few potential caveats: incomplete LAA occlusion, thrombogenicity of the suture line or of the remnant stump, atrial tears, and dehiscence of shallow sutures. The use of a transcatheter device during surgery may mitigate some of these risks. Third, the LAA is involved in atrial natriuretic peptide (ANP) secretion and surgical resection or exclusion of the LAA leads to a decrease in serum ANP level, which may lead to reduction in left atrial compliance and fluid retention. Closure rather than exclusion of the LAA may avoid these undesirable effects. The use of percutaneous devices in open procedures is not new. An example is the use of TAVR valves in MAC. Since MAC has significant risks for surgical valve replacement (need for debridement and placing sutures), some surgeons have used balloon expandable aortic valve replacements such as the Edwards SAPIEN 3, with often a device modification such as adding felt pledgets to the struts of the transcatheter aortic valve. This technology sharing is bidirectional, with surgical techniques entering the cardiac catheterization laboratory such as electrocautery for procedures such as LAMPOON (intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction) and BASILICA (Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery) obstruction. We anticipate that as Interventional Cardiologists and Cardiothoracic Surgeons continue to work together as a Heart Team, the crossover of technologies will continue to evolve, and result in optimizing clinical outcomes for our patients.