Tutorial

Aortic valve replacement, atrial fibrillation box ablation and left appendage clipping through a ministernotomy

Published: June 3, 2025

DOI: 10.1510/mmcts.2025.038

Fundamental

Surgical isolation of left atrial posterior wall (box lesion) with left atrial appendage closure are good options for treating patients with atrial fibrillation concomitant with another cardiac surgical procedure in case we prefer not to open the left atrium. We describe a full box ablation, left atrial appendage closure and aortic valve replacement through a J-shaped ministernotomy through the fourth intercostal space. The box lesion ablation is performed using the Isolator Synergy and Bipolar RF Ablation Clamp with the jaws placed in the oblique and transverse sinuses from the right side. The left appendage is excluded and electrically isolated with the AtriClip Flex-V; the aortic valve is replaced by a sutureless Perceval bioprosthesis.

This technique allows us to perform a complete box lesion and left atrial appendage closure easily for patients with paroxysmal or persistent atrial fibrillation in which we do not open the left atrium, such as those with aortic valve surgery and/or coronary artery bypass grafting.

It is a good option for treating patients with atrial fibrillation concomitant with another cardiac surgical procedure in case we prefer not to open the left atrium [1].

The patient had long-standing persistent atrial fibrillation and an aortic valve lesion.

1 – Initiating cardiopulmonary bypass and preparation (0:13)

We start with a J-shaped ministernotomy through the fourth intercostal space [2,3]. Cardiopulmonary bypass is initiated with central cannulation of the right atrium and the ascending aorta.

To create a box lesion with the radiofrequency clamp, one needs an empty heart on cardiopulmonary bypass and a cross-clamp.

We cannot place the vent suction through a pulmonary vein while performing the ablation, so venting is achieved by aortic root suction after the cardioplegia has been delivered.

We have to clear access to both the transverse and oblique sinuses sufficiently to allow proper positioning of the bipolar clamp.

Access to the oblique sinus is achieved by blunt dissection between the inferior vena cava and the inferior pulmonary vein. Access to the transverse sinus as close as possible to the roof of the left atrium can be achieved between the superior vena cava (SVC) and the superior pulmonary vein. Complete liberation of the SVC is not necessary, but a vessel loop around the SVC helps to position the bipolar clamp.
2 - Creating a box lesion (1:23)

We used Atricure Isolator Synergy & Bipolar RF Ablation Clamps.

Positioning the clamp requires gentle handling in order to freely pass the lower jaw of the clamp through the oblique sinus and the upper jaw through the transverse sinus.

Maintaining an empty heart is very important during this step.

Care must be taken that the upper jaw of the clamp moves freely on the transverse sinus. We need to ensure its positioning on top of the roof of the left atrium before advancing it.

Make sure not to bite on the left atrial appendage; the atrium should be in contact with the jaws of the clamp behind the black mark to ensure transmural effective ablation.

We apply as many rounds of ablation as necessary until the tissue impedance falls to be considered a transmural lesion in less than 5 seconds. Usually it takes 3 to 6 applications to be achieved.

When removing the clamp, be careful not to apply any extra tension on the pulmonary veins.
3 - Clipping the left atrial appendage (3:16)

Gentle traction towards the surgeon helps to better expose the left appendage, using two instruments at both sides of the left atrial appendage.

In this case, we used the V clip (AtriClip Flex-V).

Take care to include all the appendage tissue.

Bend the application shaft in order to better align the clip to the appendage neck.

Reposition the clip to reach the neck of the appendage and avoid leaving behind a pouch.
4 – Aortic valve replacement and closure (4:18)

This case demonstrates replacement of an aortic valve.

We used a Perceval valve (Corcym, Milan, Italy) through a transverse aortotomy.

Following this procedure, the patient exhibited restoration of sinus rhythm, improved cardiac function, improved lifestyle and reduced symptoms.

Three months after the operation, the patient remains in sinus rhythm with our protocol of amiodarone and oral anticoagulation. Amiodarone is removed at three months if sinus rhythm is maintained.

1. Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024;45:3314–414.

PubMed Abstract | Publisher Full Text

2. Zallé I, Son M, El-Alaoui M, Nijimbéré M, Boumzebra D. Minimally invasive and full sternotomy in aortic valve replacement: a comparative early operative outcomes. Pan Afr Med J 2021;40:68.

PubMed Abstract | Publisher Full Text

3. Bari G, Csepregi L, Bitay M, Bogáts G. A ministernotomia szerepe az aortabillentyű-sebészetben [The role of mini-sternotomy in aortic valve surgery]. Orv Hetil 2016;157:901–4. [Hungarian].

PubMed Abstract | Publisher Full Text

Authors

Sherif Negm, Bruno Chiarello, Brayan Rubio, Gustavo Woll & Manuel Castellà

Affiliation

Department of Cardiovascular Surgery, Hospital Clínic, University of Barcelona, Spain

Corresponding Author

Sherif Negm

Hospital Clínic

University of Barcelona

Barcelona

Spain

Email: dr.sherifnegm@gmail.com