Boca Raton Regional Hospital's Richard G. Cartledge, MD, FACS, has begun performing ultra-minimally invasive left atrial appendage ligation for atrial fibrillation patients who are on anticoagulants such as Coumadin, Xarelto or Effient. Dr. Cartledge, who is Chief of Cardiothoracic Surgery at the Hospital, is one of a select group of surgeons nationally using this method, which involves making two microscopic incisions in order to seal off the left atrial appendage (LAA) in patients where anticoagulants are contraindicated or who refuse to be on such medications.
Patients with atrial fibrillation, or irregular heartbeat, have a five times greater risk of suffering a stroke than people who don't have the condition, according to the Framingham Heart Study, which followed over 5,000 patients for more than 30 years. The risk is associated with the failure of the left atrium to fully evacuate blood from itself as a result of this type of arrhythmia. The blood then pools in the LAA, which is a small outpouching within the left atrium containing irregular interior surfaces called trabeculations. In patients with atrial fibrillation, clots can form in these areas and can "flick off," resulting in stroke or other serious problems.
"Your left atrial appendage is analogous to your appendix; it's something you don't need but it can kill you," said Dr. Cartledge, who completed a fellowship in thoracic surgery at Memorial Sloan-Kettering Cancer Center and a cardiac surgery fellowship at The New York Hospital/Weill Cornell Medical Center. "Whoever is on anticoagulants because of atrial fibrillation is a potential candidate for this ultra-minimally invasive procedure, which, in essence, removes the LAA from the picture much the same way as your appendix is removed."
What separates Dr. Cartledge's method from other minimally invasive procedures is the size of the incisions he makes underneath the arm in the left side of the chest. Both incisions are less than 1/5 of an inch in diameter, compared to the standard minimally invasive method that involves an incision of about 2.5 inches. The procedure also eliminates the need for a post-operative chest tube.
During the procedure, an ultra-thin, fiber optic, high-definition camera is inserted through one of the two incisions, while the other is used for an instrument port. This allows for a clear 360-degree view of inside the chest and the portion of the heart from where the LAA emanates. Dr. Cartledge then accesses the LAA and a device is inserted that seals off the LAA at its base. This totally excludes the appendage from circulation so clots can no longer be formed in that structure.
The LAA is reabsorbed by the body over a short period of time and the potential for clots is eliminated. With anticoagulants no longer being required, the procedure also greatly reduces the chance for bleeds elsewhere in the body.
"This ultra-minimally invasive procedure is efficient, safe, quick and is done with minimum discomfort," Dr. Cartledge said. "The patients essentially need only Tylenol post-operatively for pain and they can go home the next day. It really changes the paradigm of how to deal with afib in a patient that should not be on anticoagulants or doesn't want to be on anticoagulants."
In addition to his accomplishments as a heart surgeon, Dr. Cartledge has been awarded more than 100 domestic and international patents for medical devices he developed that are being used in hospitals throughout the United States, the Middle East and Europe.
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