Left Atrial Appendage Closure with Clip in Patients Undergoing Off-pump Coronary Artery Bypass Grafting

Left Atrial Appendage Closure with Clip in Patients Undergoing Off-pump Coronary Artery Bypass Grafting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Left Atrial Appendage Closure with Clip in Patients Undergoing Off-pump Coronary Artery Bypass Grafting Takafumi Hirota, Jun Takaki, Kosuke Nakata, Hideaki Hidaka, Tatsuya Horibe, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7654548/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background: We sought to investigate the safety of using left atrial appendage (LAA) closure with clip devices in patients who underwent off-pump coronary artery bypass grafting and who experienced atrial fibrillation. Methods: We applied LAA clips in 25 patients between November 2018 and May 2025. The mean age was 74 years, and 5 patients were female. All patients underwent off-pump CABG via a heart positioner and stabilizer and an LAA clip (21 with AtriClip and 4 Penditure). The mean number of coronary anastomoses was 4.0. The mean follow-up period was 28.6±17.5 months. Results: There were no complications related to the LAA clips. During the operations, we used a fluorescence imaging system in 13 patients to confirm the closure of the LAA. Moreover, in all 25 patients, postoperative enhanced computed tomography confirmed the occlusion of the LAA. No patient experienced stroke or thromboembolic eventsduring the follow-up period. Conclusions: Left atrial appendage closure with a clip was safely performed in patients undergoing off-pump CABG without harmful effects on the heart or grafts. This surgical option may be effective for stroke prevention in patients undergoing off-pump CABG. Atrial fibrillation Left atrial appendage OPCAB Figures Figure 1 Figure 2 Background Coronary artery disease and atrial fibrillation (AF) frequently coexist, presenting significant challenges in cardiovascular management [ 1 ]. Patients with this combination face substantially elevated risks of thromboembolic events, particularly stroke, which is a devastating complication with high morbidity and mortality rates [ 2 ]. The left atrial appendage (LAA) has been identified as the predominant source of thrombus formation in patients with AF, accounting for approximately 90% of cardioembolic strokes in these individuals [ 3 ]. Traditional management of stroke risk in AF patients involves long-term oral anticoagulation therapy [ 4 ]. However, this approach carries inherent risks of bleeding complications, particularly in patients undergoing cardiac surgery. Additionally, medication adherence remains problematic, and many patients have contraindications to anticoagulation therapy [ 5 ]. These limitations have prompted the development of mechanical approaches to LAA exclusion as alternative strategies for stroke prevention [ 6 ]. Among the various surgical techniques available, LAA closure with epicardial clips has emerged as a promising option. This approach allows for complete mechanical exclusion of the LAA without entering the left atrium, potentially reducing the risk of thromboembolism without necessitating long-term anticoagulation [ 7 ]. The evolution of clip-based closure systems has addressed many of the limitations of earlier techniques, offering consistent and durable LAA exclusion with minimal procedural complications [ 8 ]. Off-pump coronary artery bypass grafting (OPCAB) represents an established surgical approach for coronary revascularization that avoids cardiopulmonary bypass and its associated inflammatory response and coagulopathy [ 9 ]. The combination of OPCAB with concomitant LAA closure using clip devices presents a unique opportunity to address both coronary disease and stroke risk in a single procedure, potentially offering significant benefits for this high-risk population [ 10 ]. This paper examines the technical considerations, procedural outcomes, and clinical implications of performing LAA closure with clip devices in patients undergoing OPCAB. Patients and Methods Patients This was a retrospective observational study performed at two medical centers. All procedures were conducted by one surgeon (T. F.) between November 2018 and May 2025. There were 25 patients who underwent OPCAB with LAA closure using clip devices. The preoperative characteristics of these 25 patients are shown in Table 1 . Table 1 Preoperative characteristics of the patients Variable All patients (n = 25) Age (years) 76 [70–79] Women 5 (20.0%) Body surface area (m 2 ) 1.7 [1.5–1.7] Hypertension 19 (76.0%) Diabetes mellitus 12 (48.0%) Hyperlipidemia 17 (68.0%) Smoking history 18 (72.0%) Previous stroke 4 (16.0%) Peripheral vascular disease 3 (12.0%) Hemodialysis 5 (20.0%) Chronic occlusive pulmonary disease 3 (12.0%) Prior myocardial infarction 3 (12.0%) Chronic atrial fibrillation 9 (36.0%) Paroxysmal atrial fibrillation 16 (64.0%) Ejection fraction (%) 54 [47.5–61.6] Left atrial volume (ml) 76 [55–101] Left main trunk disease 2 (8.0%) Triple vessel disease 22 (88.0%) Data are presented as median [interquartile range] or as number (percentage). This study was approved by the Kumamoto University Research Ethics Committee (Approval No. 3229). The Institutional Review Board approved this retrospective study and waived the requirement for written consent. Continuous variables are reported as medians and interquartile ranges. Nominal variables are expressed as numbers and percentages. Operations In patients without concomitant valvular and aortic disease, our strategy for CABG was to achieve complete myocardial revascularization with the off-pump technique whenever possible. Median sternotomy was performed in all patients. All arterial grafts were harvested in a skeletonized fashion using an ultrasonic scalpel. Grafts were prepared after heparinization (300 IU/kg). The internal thoracic artery (ITA) was taken down after the papaverine solution was injected at the distal end. The technique of off-pump CABG has been described previously [ 11 ]. A deep pericardial stay suture was not used, and a commercially available heart positioner and stabilizer were applied to the heart. A bloodless field was obtained using a proximal silastic snare suture and a CO 2 blower. An intraluminal shunt was sometimes used for grafting to the right coronary artery. We bypassed all significantly diseased coronary vessels (at least a 50% diameter reduction) larger than 1 mm in diameter. Anastomosis was performed with an 8–0 polypropylene running suture using the parachute technique. When sequential grafting is performed, diamond-shaped side-to-side anastomosis and terminal T-shaped anastomosis are our preferred approaches. If necessary, the anastomosis was rotated in accordance with the angle between the graft and vessels. After all distal anastomoses were completed, anastomosis between the donor and branched arteries was performed at the end of the procedure. After all the anastomoses were completed, an LAA clip was applied. Before clip positioning, the size of the LAA base was measured using the included sizer. Before the LAA clip was applied, the heart positioner was attached to the lateral side of the left ventricle. To avoid graft capture and obstruction, we carefully handle the graft nearly passing close to the LAA during clip deployment. Both clip devices require slipping the entirety of the LAA tissue through it, parallel to the circumflex artery. At that time, an assistant grasps the tip of the LAA carefully, and the operator grasps the handle of the clip and deploys the device precisely with both hands. AtriClip TM (AtriCure Inc., Mason, OH, USA) was used from the beginning of this study; however, the use of Penditure TM (Medtronic, Inc., Minneapolis, MN, USA) began in October 2024. Confirmation of LAA occlusion Since November 2021, an intraoperative fluorescence imaging (IFI) system has been available at our institute. IFI is a technique based on the fluorescence of indocyanine green (ICG) [ 12 , 13 ]. The fluorescence is captured on a charge-coupled device video camera. Images were then recorded on the computer hard drive. We routinely use it for the assessment of graft patency during surgery in patients who undergo OPCAB. By using this technique, we determined its feasibility for confirming the occlusion of the LAA simultaneously. Occlusion of the LAA was confirmed when the fluorescence images of the LAA did not appear before or during the passage of the dye through the bypass grafts (Fig. 1 ). Moreover, early postoperative computed tomography (CT) with contrast media was performed to assess graft patency and confirm LAA occlusion in patients who did not have severe renal dysfunction 7 days after the operation (Fig. 2 ). Postoperative management and follow-up Postoperatively, intravenous heparin was administered for several days. Low-dose aspirin was started on postoperative day 1. Low-dose aspirin and warfarin or direct oral anticoagulants (DOACs) were started on postoperative day 2. Intravenous heparin was continued until warfarin or DOACs were effective. Aspirin is continued indefinitely in all patients. Follow-up was achieved by patients’ office visits or reports by family physicians. Follow-up was complete in all patients. Results The postoperative data are listed in Table 2 . The median number of distal anastomoses was 4. The left circumflex artery was reconstructed in 21 patients. Among these patients, the grafts anastomosed to the left circumflex artery were in situ left ITA in 8 patients, right ITA in 11 patients (in situ in 6 patients and free in 5 patients), and saphenous vein grafts in 2 patients. No patients converted from off-pump to on-pump CABG during the procedures. AtriClip and Penditure were used in 21 and 4 patients, respectively. The most frequently used size of AtriClip and Penditure was 45. There were no complications related to the LAA clip in any of the patients. One patient required re-exploration due to bleeding, which was caused by sternal bleeding. Table 2 Intra- and post-operative data of the patients Variable All patients (n = 25) Operation time (min) 279 [235–298] AtriClip / Penditure 21/4 Distal anastomosis 4 [ 3 – 4 ] Size of clip 45 [45–46] Operative death 0 Perioperative myocardial infarction 0 Re-exploration because of bleeding 1 (4.0%) New stroke 0 Respiratory failure 0 Pacemaker implantation 0 Deep sternal infection 0 Data are presented as median [interquartile range] or as number (percentage). IFI was used in 13 patients during the operation. In all patients, LAA occlusion was confirmed. Moreover, the patency of all the grafts was confirmed with IFI. Figure 1 shows a representative case in which the occluded LAA was shown with the IFI. Postoperative enhanced CT data were obtained for 23 patients. In all patients, occlusion of the LAA was confirmed. Moreover, the patency of all the grafts was confirmed with CT. Figure 2 shows a representative case in which the occlusion of the LAA is shown with CT. During the mean follow-up period of 28.6 ± 17.5 months, seven patients died (sepsis in three, cancer in two, and multiorgan failure in two). No patient experienced stroke or thromboembolic events during the follow-up period. All patients received low-dose aspirin, but warfarin or DOACs were prescribed to 22 patients. Discussion Necessity of LAA closure in CABG patients The coexistence of coronary artery disease and atrial fibrillation presents a complex clinical challenge, particularly with respect to stroke prevention. Patients with AF undergoing CABG remain at substantial risk for thromboembolic events, with the left atrial appendage serving as the primary source of cardiac emboli in approximately 90% of cases [ 3 ]. While anticoagulation therapy remains the standard approach for stroke prevention in AF patients, this strategy poses significant challenges in the perioperative and postoperative periods following cardiac surgery. The inherent bleeding risks associated with anticoagulation, coupled with issues of medication adherence and contraindications in certain patient populations, have driven the development of mechanical LAA exclusion techniques as a viable alternative [ 5 ]. Our study demonstrated that concomitant LAA closure during CABG procedures can be safely performed without compromising surgical outcomes or graft integrity. This approach addresses the dual pathology of coronary disease and AF-related stroke risk in a single intervention, potentially eliminating the need for long-term anticoagulation and its associated complications. Advantages of clip-based LAA closure Among the various surgical techniques available for LAA exclusion, clip-based closure has emerged as a particularly attractive option because of its simplicity, safety, and efficacy. Unlike other methods, such as surgical ligation or stapling, clip devices provide consistent and complete LAA exclusion without requiring entry into the left atrium [ 7 , 8 ]. The technical advantages of clip-based closure include (1) ease of application with minimal learning curve, (2) consistent closure regardless of LAA morphology, (3) absence of suture line complications, and (4) immediate confirmation of complete exclusion. Our experience with 25 patients confirms these advantages, with no clip-related complications observed in any case. The epicardial approach used with clip devices is particularly well suited for concomitant procedures during CABG, as it can be performed after completion of all coronary anastomoses without interfering with the revascularization strategy. After revascularization with OPCAB, hemodynamics are more stable, and LAA clips are easier to perform. Moreover, this timing allows for optimal visualization and positioning of the clip while avoiding potential graft compromise. Our experience encompasses both AtriClip (n = 21) and Penditure (n = 4) closure systems, providing insight into the practical differences between these devices. The AtriClip system, which we have used extensively, offers proven efficacy and durability with well-established outcomes in clinical practice. The device provides reliable closure with sizes ranging from 35 mm to 50 mm, accommodating various LAA anatomies. The more recently introduced Penditure system offers several potential advantages over AtriClip. The Penditure device features a simplified deployment mechanism that may reduce procedural complexity and operative time. Its fabric-free design may reduce the chances of inflammation and adhesions with adjacent tissue [ 14 ]. The design allows for easier positioning and deployment, particularly in challenging anatomical situations. However, our limited experience with Penditure (4 cases) precludes definitive conclusions about long-term outcomes compared with AtriClip. Both systems demonstrated 100% acute closure rates in our series, as confirmed by intraoperative and postoperative imaging. The choice between systems may depend on surgeon preference, LAA anatomy, and device availability rather than significant clinical differences. Intraoperative confirmation using fluorescence imaging Accurate confirmation of complete LAA closure is crucial for procedural success and stroke prevention. While transesophageal echocardiography (TEE) has been the traditional method for intraoperative assessment, we have successfully employed IFI as an alternative approach [ 12 , 13 ]. IFI offers several advantages over TEE for LAA closure confirmation: (1) real-time visualization of LAA exclusion during dye transit, (2) simultaneous assessment of graft patency, (3) noninvasive nature without requiring additional equipment or personnel, and (4) permanent digital recording for documentation. In our series of 17 patients where IFI was utilized, complete LAA occlusion was confirmed in all patients, demonstrating the reliability of this technique. Long-term outcomes and future considerations While our study demonstrated favorable acute results with 100% closure rates on early postoperative CT images, the long-term durability and clinical efficacy of clip-based LAA closure require ongoing investigation. Potential concerns include device-related inflammation leading to graft compromise, incomplete closure due to tissue remodeling, and the development of peridevice leaks over time. The inflammatory response to clip devices and their potential impact on nearby coronary grafts represents a particular concern in patients undergoing coronary artery bypass grafting. While our acute results show no evidence of graft compromise, longer follow-up with serial imaging and clinical assessment is necessary to ensure maintained graft patency and LAA closure. Study limitations This study has several limitations that must be acknowledged. The retrospective design and single-surgeon experience limit the generalizability of our findings. The sample size was relatively small, and only short-term procedural safety was observed in this study. The long-term outcomes, including chronic inflammation from the foreign body, the risk of adhesion to and compromise of adjacent bypass grafts, device durability, and late-onset pericardial effusion, were not assessed. Additionally, the lack of a control group prevents comparisons with alternative stroke prevention strategies. Conclusions Our experience demonstrates that LAA closure with clip devices can be safely performed in patients undergoing OPCAB. This technique offers a practical solution for addressing stroke risk in AF patients. The use of intraoperative fluorescence imaging provides reliable confirmation of closure success. However, long-term studies are needed to establish the durability of closure and its clinical efficacy in stroke prevention. Abbreviations AF: Atrial fibrillation LAA: Left atrial appendage OPCAB: Off-pump coronary artery bypass grafting ITA: Internal thoracic artery TEE: Transesophageal echocardiography IFI: Intraoperative fluorescence imaging CT: Computed tomography Declarations Ethics approval and consent to participate The study protocol was approved by the Institutional Review Board of the Kumamoto University Research Ethics Committee (Approval no. 3229). Because of the retrospective nature of the study, the requirement for informed consent was waived. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. Author Contributions TF: Drafting the work or reviewing it critically for important intellectual content. TH: Data collection, interpretation of data and manuscript editing. JT: writing of manuscript. KN: Data collection and interpretation of data. HH: Data collection and interpretation of data. TH: Data collection and interpretation of data. ST: Data collection and interpretation of data. TY: Conception and design of the work, data collection, interpretation of data, and writing of manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to its accuracy or integrity. References January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;140:e125-51. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983-8. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755-9. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. Eur Heart J. 2021;42:373-498. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomized trials. Lancet. 2014;383:955-62. Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomized noninferiority trial. Lancet. 2009;374:534-42. Caliskan E, Sahin A, Yilmaz M, et al. Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery. Europace. 2018;20:e105-14. Salzberg SP, Plass A, Emmert MY, et al. Left atrial appendage clip occlusion: early clinical results. J Thorac Cardiovasc Surg. 2010;139:1269-74. Lamy A, Devereaux PJ, Prabhakaran D, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012;366:1489-97. Suwalski G, Emery R, Gryszko L,et al. Early operative comparison of two epicardial left atrial appendage occluding systems applied during off-pump coronary revascularisation in patients with persistent atrial fibrillation. Kardiochir Torakochirurgia Pol. 2016;13:10-4. Fukui T, Takanashi S, Hosoda Y, Suehiro S. Early and midterm results of off-pump coronary artery bypass grafting. Ann Thorac Surg 2007;83:115-9. Taggart DP, Choudhary B, Anastasiadis K, Abu-Omar Y, Balacumaraswami L, Pigott DW. Preliminary experience with a novel intraoperative fluorescence imaging technique to evaluate the patency of bypass grafts in total arterial revascularization. Ann Thorac Surg. 2003;75:870-3. Fukui T. Intraoperative graft assessment during coronary artery bypass surgery. Gen Thorac Cardiovasc Surg. 2015;63:123-30. Torregrossa G, Baudo M, Yakobitis A, Murray C, Kappetein AP. Surgical implant of Medtronic Penditure left atrial appendage exclusion clip during off-pump bilateral internal thoracic artery coronary artery bypass grafting. Ann Cardiothorac Surg. 2024;13:182-3. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 22 Feb, 2026 Reviews received at journal 22 Feb, 2026 Reviews received at journal 11 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviewers invited by journal 23 Dec, 2025 Editor assigned by journal 19 Sep, 2025 Submission checks completed at journal 19 Sep, 2025 First submitted to journal 19 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7654548","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":564868445,"identity":"f9055c04-6154-4e51-bf4a-945964dbd59b","order_by":0,"name":"Takafumi Hirota","email":"","orcid":"","institution":"Kumamoto University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takafumi","middleName":"","lastName":"Hirota","suffix":""},{"id":564868446,"identity":"3a43993a-1ed6-47e1-8f2c-3e429e59e333","order_by":1,"name":"Jun Takaki","email":"","orcid":"","institution":"Kumamoto University 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16:31:36","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":62899,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7654548/v1/29794f0524fb85cd02346f77.html"},{"id":99318181,"identity":"d539917a-023f-46d3-87e6-796433d5dffb","added_by":"auto","created_at":"2025-12-31 16:31:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":403849,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative fluorescence imaging showing the patency of the grafts and occlusion of the left atrial appendage.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7654548/v1/b4adda25af137396c2dc45cc.png"},{"id":99318166,"identity":"a690acf0-e330-434b-bcb7-32b3fd5e9649","added_by":"auto","created_at":"2025-12-31 16:31:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":643060,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography image showing the graft patency and occlusion of the left atrial appendage by a clip.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7654548/v1/a04dbc2aa56e1538c1c5e97c.png"},{"id":107927681,"identity":"0e873534-8b15-4102-b38f-2390b97b9243","added_by":"auto","created_at":"2026-04-27 16:01:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1499627,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7654548/v1/9ec193ee-cf16-487d-b9ad-aacceb9ebe1f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Left Atrial Appendage Closure with Clip in Patients Undergoing Off-pump Coronary Artery Bypass Grafting","fulltext":[{"header":"Background","content":"\u003cp\u003eCoronary artery disease and atrial fibrillation (AF) frequently coexist, presenting significant challenges in cardiovascular management [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Patients with this combination face substantially elevated risks of thromboembolic events, particularly stroke, which is a devastating complication with high morbidity and mortality rates [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The left atrial appendage (LAA) has been identified as the predominant source of thrombus formation in patients with AF, accounting for approximately 90% of cardioembolic strokes in these individuals [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTraditional management of stroke risk in AF patients involves long-term oral anticoagulation therapy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, this approach carries inherent risks of bleeding complications, particularly in patients undergoing cardiac surgery. Additionally, medication adherence remains problematic, and many patients have contraindications to anticoagulation therapy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These limitations have prompted the development of mechanical approaches to LAA exclusion as alternative strategies for stroke prevention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the various surgical techniques available, LAA closure with epicardial clips has emerged as a promising option. This approach allows for complete mechanical exclusion of the LAA without entering the left atrium, potentially reducing the risk of thromboembolism without necessitating long-term anticoagulation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The evolution of clip-based closure systems has addressed many of the limitations of earlier techniques, offering consistent and durable LAA exclusion with minimal procedural complications [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOff-pump coronary artery bypass grafting (OPCAB) represents an established surgical approach for coronary revascularization that avoids cardiopulmonary bypass and its associated inflammatory response and coagulopathy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The combination of OPCAB with concomitant LAA closure using clip devices presents a unique opportunity to address both coronary disease and stroke risk in a single procedure, potentially offering significant benefits for this high-risk population [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis paper examines the technical considerations, procedural outcomes, and clinical implications of performing LAA closure with clip devices in patients undergoing OPCAB.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis was a retrospective observational study performed at two medical centers. All procedures were conducted by one surgeon (T. F.) between November 2018 and May 2025. There were 25 patients who underwent OPCAB with LAA closure using clip devices. The preoperative characteristics of these 25 patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative characteristics of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 [70\u0026ndash;79]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody surface area (m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7 [1.5\u0026ndash;1.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (76.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (48.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperlipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (68.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (72.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (16.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral vascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (12.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemodialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic occlusive pulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (12.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior myocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (12.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic atrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (36.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParoxysmal atrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (64.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEjection fraction (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 [47.5\u0026ndash;61.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft atrial volume (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 [55\u0026ndash;101]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft main trunk disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriple vessel disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (88.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as median [interquartile range] or as number (percentage).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e This study was approved by the Kumamoto University Research Ethics Committee (Approval No. 3229). The Institutional Review Board approved this retrospective study and waived the requirement for written consent.\u003c/p\u003e \u003cp\u003eContinuous variables are reported as medians and interquartile ranges. Nominal variables are expressed as numbers and percentages.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOperations\u003c/h3\u003e\n\u003cp\u003eIn patients without concomitant valvular and aortic disease, our strategy for CABG was to achieve complete myocardial revascularization with the off-pump technique whenever possible. Median sternotomy was performed in all patients. All arterial grafts were harvested in a skeletonized fashion using an ultrasonic scalpel. Grafts were prepared after heparinization (300 IU/kg). The internal thoracic artery (ITA) was taken down after the papaverine solution was injected at the distal end. The technique of off-pump CABG has been described previously [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A deep pericardial stay suture was not used, and a commercially available heart positioner and stabilizer were applied to the heart. A bloodless field was obtained using a proximal silastic snare suture and a CO\u003csub\u003e2\u003c/sub\u003e blower. An intraluminal shunt was sometimes used for grafting to the right coronary artery. We bypassed all significantly diseased coronary vessels (at least a 50% diameter reduction) larger than 1 mm in diameter. Anastomosis was performed with an 8\u0026ndash;0 polypropylene running suture using the parachute technique. When sequential grafting is performed, diamond-shaped side-to-side anastomosis and terminal T-shaped anastomosis are our preferred approaches. If necessary, the anastomosis was rotated in accordance with the angle between the graft and vessels. After all distal anastomoses were completed, anastomosis between the donor and branched arteries was performed at the end of the procedure.\u003c/p\u003e \u003cp\u003eAfter all the anastomoses were completed, an LAA clip was applied. Before clip positioning, the size of the LAA base was measured using the included sizer. Before the LAA clip was applied, the heart positioner was attached to the lateral side of the left ventricle. To avoid graft capture and obstruction, we carefully handle the graft nearly passing close to the LAA during clip deployment. Both clip devices require slipping the entirety of the LAA tissue through it, parallel to the circumflex artery. At that time, an assistant grasps the tip of the LAA carefully, and the operator grasps the handle of the clip and deploys the device precisely with both hands.\u003c/p\u003e \u003cp\u003eAtriClip \u003csup\u003eTM\u003c/sup\u003e (AtriCure Inc., Mason, OH, USA) was used from the beginning of this study; however, the use of Penditure \u003csup\u003eTM\u003c/sup\u003e (Medtronic, Inc., Minneapolis, MN, USA) began in October 2024.\u003c/p\u003e\n\u003ch3\u003eConfirmation of LAA occlusion\u003c/h3\u003e\n\u003cp\u003eSince November 2021, an intraoperative fluorescence imaging (IFI) system has been available at our institute. IFI is a technique based on the fluorescence of indocyanine green (ICG) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The fluorescence is captured on a charge-coupled device video camera. Images were then recorded on the computer hard drive. We routinely use it for the assessment of graft patency during surgery in patients who undergo OPCAB. By using this technique, we determined its feasibility for confirming the occlusion of the LAA simultaneously. Occlusion of the LAA was confirmed when the fluorescence images of the LAA did not appear before or during the passage of the dye through the bypass grafts (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMoreover, early postoperative computed tomography (CT) with contrast media was performed to assess graft patency and confirm LAA occlusion in patients who did not have severe renal dysfunction 7 days after the operation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003ePostoperative management and follow-up\u003c/h3\u003e\n\u003cp\u003ePostoperatively, intravenous heparin was administered for several days. Low-dose aspirin was started on postoperative day 1. Low-dose aspirin and warfarin or direct oral anticoagulants (DOACs) were started on postoperative day 2. Intravenous heparin was continued until warfarin or DOACs were effective. Aspirin is continued indefinitely in all patients.\u003c/p\u003e \u003cp\u003eFollow-up was achieved by patients\u0026rsquo; office visits or reports by family physicians. Follow-up was complete in all patients.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe postoperative data are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The median number of distal anastomoses was 4. The left circumflex artery was reconstructed in 21 patients. Among these patients, the grafts anastomosed to the left circumflex artery were in situ left ITA in 8 patients, right ITA in 11 patients (in situ in 6 patients and free in 5 patients), and saphenous vein grafts in 2 patients. No patients converted from off-pump to on-pump CABG during the procedures. AtriClip and Penditure were used in 21 and 4 patients, respectively. The most frequently used size of AtriClip and Penditure was 45. There were no complications related to the LAA clip in any of the patients. One patient required re-exploration due to bleeding, which was caused by sternal bleeding.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntra- and post-operative data of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e279 [235\u0026ndash;298]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtriClip / Penditure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21/4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal anastomosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of clip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 [45\u0026ndash;46]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerioperative myocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRe-exploration because of bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePacemaker implantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep sternal infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as median [interquartile range] or as number (percentage).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIFI was used in 13 patients during the operation. In all patients, LAA occlusion was confirmed. Moreover, the patency of all the grafts was confirmed with IFI. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows a representative case in which the occluded LAA was shown with the IFI. Postoperative enhanced CT data were obtained for 23 patients. In all patients, occlusion of the LAA was confirmed. Moreover, the patency of all the grafts was confirmed with CT. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows a representative case in which the occlusion of the LAA is shown with CT.\u003c/p\u003e \u003cp\u003eDuring the mean follow-up period of 28.6\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5 months, seven patients died (sepsis in three, cancer in two, and multiorgan failure in two). No patient experienced stroke or thromboembolic events during the follow-up period. All patients received low-dose aspirin, but warfarin or DOACs were prescribed to 22 patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eNecessity of LAA closure in CABG patients\u003c/h2\u003e \u003cp\u003eThe coexistence of coronary artery disease and atrial fibrillation presents a complex clinical challenge, particularly with respect to stroke prevention. Patients with AF undergoing CABG remain at substantial risk for thromboembolic events, with the left atrial appendage serving as the primary source of cardiac emboli in approximately 90% of cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While anticoagulation therapy remains the standard approach for stroke prevention in AF patients, this strategy poses significant challenges in the perioperative and postoperative periods following cardiac surgery. The inherent bleeding risks associated with anticoagulation, coupled with issues of medication adherence and contraindications in certain patient populations, have driven the development of mechanical LAA exclusion techniques as a viable alternative [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Our study demonstrated that concomitant LAA closure during CABG procedures can be safely performed without compromising surgical outcomes or graft integrity. This approach addresses the dual pathology of coronary disease and AF-related stroke risk in a single intervention, potentially eliminating the need for long-term anticoagulation and its associated complications.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAdvantages of clip-based LAA closure\u003c/h3\u003e\n\u003cp\u003eAmong the various surgical techniques available for LAA exclusion, clip-based closure has emerged as a particularly attractive option because of its simplicity, safety, and efficacy. Unlike other methods, such as surgical ligation or stapling, clip devices provide consistent and complete LAA exclusion without requiring entry into the left atrium [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The technical advantages of clip-based closure include (1) ease of application with minimal learning curve, (2) consistent closure regardless of LAA morphology, (3) absence of suture line complications, and (4) immediate confirmation of complete exclusion. Our experience with 25 patients confirms these advantages, with no clip-related complications observed in any case. The epicardial approach used with clip devices is particularly well suited for concomitant procedures during CABG, as it can be performed after completion of all coronary anastomoses without interfering with the revascularization strategy. After revascularization with OPCAB, hemodynamics are more stable, and LAA clips are easier to perform. Moreover, this timing allows for optimal visualization and positioning of the clip while avoiding potential graft compromise.\u003c/p\u003e \u003cp\u003eOur experience encompasses both AtriClip (n\u0026thinsp;=\u0026thinsp;21) and Penditure (n\u0026thinsp;=\u0026thinsp;4) closure systems, providing insight into the practical differences between these devices. The AtriClip system, which we have used extensively, offers proven efficacy and durability with well-established outcomes in clinical practice. The device provides reliable closure with sizes ranging from 35 mm to 50 mm, accommodating various LAA anatomies. The more recently introduced Penditure system offers several potential advantages over AtriClip. The Penditure device features a simplified deployment mechanism that may reduce procedural complexity and operative time. Its fabric-free design may reduce the chances of inflammation and adhesions with adjacent tissue [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The design allows for easier positioning and deployment, particularly in challenging anatomical situations. However, our limited experience with Penditure (4 cases) precludes definitive conclusions about long-term outcomes compared with AtriClip. Both systems demonstrated 100% acute closure rates in our series, as confirmed by intraoperative and postoperative imaging. The choice between systems may depend on surgeon preference, LAA anatomy, and device availability rather than significant clinical differences.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative confirmation using fluorescence imaging\u003c/h2\u003e \u003cp\u003eAccurate confirmation of complete LAA closure is crucial for procedural success and stroke prevention. While transesophageal echocardiography (TEE) has been the traditional method for intraoperative assessment, we have successfully employed IFI as an alternative approach [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. IFI offers several advantages over TEE for LAA closure confirmation: (1) real-time visualization of LAA exclusion during dye transit, (2) simultaneous assessment of graft patency, (3) noninvasive nature without requiring additional equipment or personnel, and (4) permanent digital recording for documentation. In our series of 17 patients where IFI was utilized, complete LAA occlusion was confirmed in all patients, demonstrating the reliability of this technique.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLong-term outcomes and future considerations\u003c/h2\u003e \u003cp\u003eWhile our study demonstrated favorable acute results with 100% closure rates on early postoperative CT images, the long-term durability and clinical efficacy of clip-based LAA closure require ongoing investigation. Potential concerns include device-related inflammation leading to graft compromise, incomplete closure due to tissue remodeling, and the development of peridevice leaks over time. The inflammatory response to clip devices and their potential impact on nearby coronary grafts represents a particular concern in patients undergoing coronary artery bypass grafting. While our acute results show no evidence of graft compromise, longer follow-up with serial imaging and clinical assessment is necessary to ensure maintained graft patency and LAA closure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations that must be acknowledged. The retrospective design and single-surgeon experience limit the generalizability of our findings. The sample size was relatively small, and only short-term procedural safety was observed in this study. The long-term outcomes, including chronic inflammation from the foreign body, the risk of adhesion to and compromise of adjacent bypass grafts, device durability, and late-onset pericardial effusion, were not assessed. Additionally, the lack of a control group prevents comparisons with alternative stroke prevention strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur experience demonstrates that LAA closure with clip devices can be safely performed in patients undergoing OPCAB. This technique offers a practical solution for addressing stroke risk in AF patients. The use of intraoperative fluorescence imaging provides reliable confirmation of closure success. However, long-term studies are needed to establish the durability of closure and its clinical efficacy in stroke prevention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAF: Atrial fibrillation\u003c/p\u003e\n\u003cp\u003eLAA: Left atrial appendage\u003c/p\u003e\n\u003cp\u003eOPCAB: Off-pump coronary artery bypass grafting\u003c/p\u003e\n\u003cp\u003eITA: Internal thoracic artery\u003c/p\u003e\n\u003cp\u003eTEE: Transesophageal echocardiography\u003c/p\u003e\n\u003cp\u003eIFI: Intraoperative fluorescence imaging\u003c/p\u003e\n\u003cp\u003eCT: Computed tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Review Board of the Kumamoto University Research Ethics Committee (Approval no. 3229). Because of the retrospective nature of the study, the requirement for informed consent was waived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor Contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTF: Drafting the work or reviewing it critically for important intellectual content. TH: Data collection, interpretation of data and manuscript editing. JT: writing of manuscript. KN: Data collection and interpretation of data. HH: Data collection and interpretation of data. TH: Data collection and interpretation of data. ST: Data collection and interpretation of data. TY: Conception and design of the work, data collection, interpretation of data, and writing of manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to its accuracy or integrity.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJanuary CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;140:e125-51.\u003c/li\u003e\n\u003cli\u003eWolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983-8.\u003c/li\u003e\n\u003cli\u003eBlackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755-9.\u003c/li\u003e\n\u003cli\u003eHindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. Eur Heart J. 2021;42:373-498.\u003c/li\u003e\n\u003cli\u003eRuff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomized trials. Lancet. 2014;383:955-62.\u003c/li\u003e\n\u003cli\u003eHolmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomized noninferiority trial. Lancet. 2009;374:534-42.\u003c/li\u003e\n\u003cli\u003eCaliskan E, Sahin A, Yilmaz M, et al. Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery. Europace. 2018;20:e105-14.\u003c/li\u003e\n\u003cli\u003eSalzberg SP, Plass A, Emmert MY, et al. Left atrial appendage clip occlusion: early clinical results. J Thorac Cardiovasc Surg. 2010;139:1269-74.\u003c/li\u003e\n\u003cli\u003eLamy A, Devereaux PJ, Prabhakaran D, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012;366:1489-97.\u003c/li\u003e\n\u003cli\u003eSuwalski G, Emery R, Gryszko L,et al. Early operative comparison of two epicardial left atrial appendage occluding systems applied during off-pump coronary revascularisation in patients with persistent atrial fibrillation. Kardiochir Torakochirurgia Pol. 2016;13:10-4.\u003c/li\u003e\n\u003cli\u003eFukui T, Takanashi S, Hosoda Y, Suehiro S. Early and midterm results of off-pump coronary artery bypass grafting. Ann Thorac Surg 2007;83:115-9.\u003c/li\u003e\n\u003cli\u003eTaggart DP, Choudhary B, Anastasiadis K, Abu-Omar Y, Balacumaraswami L, Pigott DW. Preliminary experience with a novel intraoperative fluorescence imaging technique to evaluate the patency of bypass grafts in total arterial revascularization. Ann Thorac Surg. 2003;75:870-3.\u003c/li\u003e\n\u003cli\u003eFukui T. Intraoperative graft assessment during coronary artery bypass surgery. Gen Thorac Cardiovasc Surg. 2015;63:123-30.\u003c/li\u003e\n\u003cli\u003eTorregrossa G, Baudo M, Yakobitis A, Murray C, Kappetein AP. Surgical implant of Medtronic Penditure left atrial appendage exclusion clip during off-pump bilateral internal thoracic artery coronary artery bypass grafting. Ann Cardiothorac Surg. 2024;13:182-3.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Atrial fibrillation, Left atrial appendage, OPCAB","lastPublishedDoi":"10.21203/rs.3.rs-7654548/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7654548/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eWe sought to investigate the safety of using left atrial appendage (LAA) closure with clip devices in patients who underwent off-pump coronary artery bypass grafting and who experienced atrial fibrillation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe applied LAA clips in 25 patients between November 2018 and May 2025. The mean age was 74 years, and 5 patients were female. All patients underwent off-pump CABG via a heart positioner and stabilizer and an LAA clip (21 with AtriClip and 4 Penditure). The mean number of coronary anastomoses was 4.0. The mean follow-up period was 28.6±17.5 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e There were no complications related to the LAA clips. During the operations, we used a fluorescence imaging system in 13 patients to confirm the closure of the LAA. Moreover, in all 25 patients, postoperative enhanced computed tomography confirmed the occlusion of the LAA. No patient experienced stroke or thromboembolic eventsduring the follow-up period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eLeft atrial appendage closure with a clip was safely performed in patients undergoing off-pump CABG without harmful effects on the heart or grafts. This surgical option may be effective for stroke prevention in patients undergoing off-pump CABG.\u003c/p\u003e","manuscriptTitle":"Left Atrial Appendage Closure with Clip in Patients Undergoing Off-pump Coronary Artery Bypass Grafting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 08:49:33","doi":"10.21203/rs.3.rs-7654548/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-23T04:16:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-22T18:41:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-11T05:10:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12008641206130449072957864577419518643","date":"2026-02-11T01:27:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225796845875992425777350040001040405524","date":"2026-02-10T10:27:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173557187200281594433058962383752884338","date":"2026-01-17T12:01:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-23T06:48:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-19T11:45:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-19T11:45:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-09-19T05:05:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"185e33a2-623b-4a9c-b593-6557e4a54545","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:00:47+00:00","versionOfRecord":{"articleIdentity":"rs-7654548","link":"https://doi.org/10.1186/s13019-026-04204-8","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-04-25 15:57:30","publishedOnDateReadable":"April 25th, 2026"},"versionCreatedAt":"2025-12-30 08:49:33","video":"","vorDoi":"10.1186/s13019-026-04204-8","vorDoiUrl":"https://doi.org/10.1186/s13019-026-04204-8","workflowStages":[]},"version":"v1","identity":"rs-7654548","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7654548","identity":"rs-7654548","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}