Surgical Ablation of Atrial Fibrillation Using the Left Atrial Roof Approach

Background: Minimally invasive surgical ablation has demonstrated favorable outcomes when performed during mitral and tricuspid valve procedures; however, its application in proximal aortic and aortic valve procedures remains challenging. We present the left atrial (LA) roof approach via upper mini-sternotomy as an alternative technique. Methods: The LA was exposed by transecting or laterally retracting the ascending aorta, followed by a 3-4 cm transverse incision near the ostia of the upper pulmonary veins (PVs). A left semicircular cryoablation lesion was created from the left margin of the LA roof incision and extended posterolaterally to encircle the left PVs. A right arc-shaped lesion was created from the right margin, extended posterolaterally to encircle the right PVs, and terminated at the posterior mitral annulus adjacent to the P3 scallop. Together, these lesions constituted a complete box lesion for PV isolation in conjunction with mitral isthmus cryoablation. Results: From June 2018 to February 2023, 23 patients underwent surgical ablation using the LA roof approach. Aortic valve replacement, performed alone or combined with other procedures, was the most common procedure (60.9%), followed by arch repair (30.4%) and root replacement (26.1%). The median cross-clamp and bypass times were 92 and 117 minutes, respectively. No early deaths, cases requiring dialysis, or wound infections occurred. Three patients (13.0%) required permanent pacemaker implantation. Freedom from atrial fibrillation recurrence was 91.3% at 1 year and 82.6% at 2 years. Conclusion: In this preliminary experience, the LA roof approach via upper mini-sternotomy yielded favorable early postoperative and mid-term rhythm outcomes.