Clip and cure: A minimally invasive strategy for left atrial appendage exclusion and left atrial cryoablation lesion...

Surgical exclusion of the left atrial appendage (LAA) combined with left atrial cryoablation is an important component of atrial fibrillation management during mitral valve surgery. A right minithoracotomy approach offers direct access to the transverse and oblique sinuses, enabling controlled LAA clip deployment and delivery of cryoablation lesions.

A video-assisted right minithoracotomy was performed through the fourth intercostal space. Intraoperative transesophageal echocardiography guided LAA sizing with a 10-mm safety margin and confirmed adequate distance from the circumflex artery and warfarin ridge. After initiation of cardiopulmonary bypass, the LAA was mobilized and excluded using a preselected clip introduced through the transverse sinus under direct visualization, avoiding adjacent structures. A left atrial cryoablation lesion set was then performed, including 4 components: endocardial application toward the mitral annulus, epicardial convergence across the coronary sinus, and sequential roof and inferior pulmonary vein lines completing a box lesion pattern. Continuous probe contact with controlled -60 °C was used to achieve transmural lesions.

The minimally invasive approach provided excellent visualization of the transverse sinus, allowing precise LAA clip placement and secure appendage exclusion. The cryoablation sequence facilitated the creation of contiguous and transmural lesion lines, completing a comprehensive left atrial lesion set through a limited thoracotomy.

A minimally invasive right minithoracotomy technique allows reliable LAA exclusion combined with left atrial cryoablation during mitral valve surgery. Direct visualization through the transverse sinus supports accurate clip deployment, whereas a structured cryoablation sequence enables consistent lesion formation for the surgical treatment of atrial fibrillation.