Endocardial obliterative left atrial appendage closure by inverted purse-string plication

To describe an endocardial obliterative left atrial appendage closure (LAAC) technique using inverted appendage purse-string plication added to 2-layer orifice closure and to evaluate anatomic and clinical outcomes in minimally invasive and robotic mitral surgery.

This retrospective study included consecutive patients who underwent robotic mitral valve surgery, or atrial septal defect repair with tricuspid intervention, with concomitant endocardial obliterative LAAC between April 2024 and June 2025. The technique inverts the distal half of the left atrial appendage (LAA), compacts it with a 3-0 barbed purse-string along an oblique line in the pectinate muscle, restores native orientation, then performs a 2-layer orifice closure with polypropylene sutures. Pre- and postoperative electrocardiogram-gated cardiac computed tomography (ECG-CT) was used to assess anatomy. The primary end point was complete closure, defined as absence of contrast filling within the LAA body in early and delayed phases. Analyses were descriptive.

Twenty-four patients (median age, 71.5 years) underwent endocardial obliterative LAAC with the da Vinci system without conversion or intraoperative bleeding requiring intervention. There were no perioperative deaths, strokes, myocardial ischemic events, re-explorations, or left circumflex artery injuries. At 3 to 6 months, ECG-CT in all patients showed complete closure with no contrast inflow, residual lumen, pericardial effusion, and periappendage hematoma.

Endocardial obliterative LAAC using inverted appendage purse-string plication followed by 2-layer orifice closure is a simple, inexpensive, and safe adjunct to minimally invasive mitral surgery, achieving ECG-CT-confirmed complete anatomic closure in this early series and potentially enhancing the effectiveness of surgical LAAC.