Left Atrial Appendage Exclusion via Right Minithoracotomy Using an Epicardial Clip Device During Minimally Invasive...

Background and Objectives: Left atrial appendage (LAA) closure is a Class I recommendation in patients with atrial fibrillation to reduce the risk of cardioembolic stroke. Achieving reliable and complete LAA exclusion during minimally invasive mitral valve surgery via right minithoracotomy remains technically challenging. We report here to our knowledge the largest series of a novel technique for LAA exclusion using an epicardial clip device applied via right minithoracotomy during minimally invasive mitral valve surgery. Materials and Methods: Between June 2023 and May 2026, 40 patients with atrial fibrillation underwent minimally invasive mitral valve surgery via right minithoracotomy with concomitant LAA exclusion. Cardiopulmonary bypass was established via percutaneous femoral cannulation. Following completion of the intracardiac procedure and prior to aortic cross-clamp removal, a suture was placed around the LAA base via the transverse sinus and used to guide clip deployment under direct vision. Successful closure was confirmed by intraoperative transesophageal echocardiography. Results: Mean patient age was 66.6 ± 8.0 years; 21 patients (53%) were female. Mitral valve repair was performed in 36 patients (90%) and replacement in 4 (10%). Concomitant cryoablation for AF was performed in 31 patients (78%). Successful LAA clip deployment was achieved in all 40 patients (100%). The 35 mm clip was used in 36 patients (90%), the 40 mm clip in 3 patients (8%), and the 45 mm clip in 1 patient (2%). Mean total operative time was 183 ± 58 min; mean CPB time was 134 ± 42 min; mean aortic cross-clamp time was 70 ± 27 min. In-hospital mortality was 0%. One patient (3%) required re-thoracotomy for bleeding, one developed a postoperative stroke, and two required ECMO support. Median hospital stay was 9 days. At discharge, 18 patients (45%) were in sinus rhythm; among the 31 who underwent concomitant cryoablation, 16 (52%) were discharged in sinus rhythm. Conclusions: Minimally invasive LAA exclusion is feasible and safe when performed via right minithoracotomy during minimally invasive mitral valve surgery. The technique achieves high rates of successful deployment and avoids the need for additional incisions or access sites. This approach represents a valuable addition to the armamentarium of concomitant stroke prevention strategies in patients with AF undergoing minimally invasive valvular surgery.