Minimally invasive surgical treatment of lone atrial fibrillation (AF) is indicated in patients at risk of recurrence after catheter ablation of AF.

We evaluated our initial experience of surgical ablation of AF and left appendage exclusion by a bilateral thoracoscopic approach with a non-irrigated bipolar radiofrequency system (Atricure).

Between January 2016 and March 2017, 8 patients underwent an off-pump, beating heart, lone AF surgical ablation with the Atricure system. Surgical technique starts with a right thoracic approach trough three ports. After dissection of transverse and oblique sinuses, a light dissector (Wolff Lumitip, Fig. 1a) is used to guide a bipolar clamp around pulmonary veins (Sinergy Clamp, Fig. 1b); a linear transmural lesion is created with bi-directional bipolar radiofrequency on the antrum of pulmonary veins. Two other lesions on the roof and on the floor of left atrium (LA) are created with a bipolar unidirectional catheter (CoolRail, Fig. 1c). After creating the same pattern of lesions on left side, the left appendage is excluded with a clip (Atriclip Pro, Fig. 1d). Preoperative characteristics are resumed in Table 1.

There were no postoperative major complications. Mean postoperative length of stay was 13 days (7–20), longest hospitalizations were due to persistent pleural effusions through thoracic drains in two patients and infection of thoracic ports in one patient. A patient died 10 months postoperatively of alcoholic cirrhosis. After a blanking period of 3 months, all patients were free from AF; 7 patients were under anticoagulant treatment; three of them were under VKA and 4 under NOACS. Only one patient was under anti-arrhythmic drugs.

AF surgical ablation and left appendage exclusion seem to be safe and effective for patients at risk of recurrence after catheter ablation of AF. A longer follow-up is mandatory to confirm these results in the long term.