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A Technique for Clipping the Left Atrial Appendage Using a Right Mini-Anterolateral Thoracotomy During Surgical Correction of Mitral Valve Regurgitation
Joseph A. Di Como1, Walid M. Elzomor2, Mark W. Connolly2, Kourosh T. Asgarian2.
1St. George's University School of Medicine, St. George's, Grenada, 2St. Joseph's Regional Medical Center, Paterson, NJ, USA.

OBJECTIVE: This manuscript aims to illustrate the accessibility of the left atrial appendage through a right mini-anterolateral thoracotomy and how to successfully place an atrial-clipping device when repairing the mitral valve through a combined surgical technique.
METHODS: After accessing the mitral valve for replacement or repair using a right mini-anterolateral thoracotomy, the heart is assessed for mitral regurgitation and de-aired before the atriotomy is closed with two layers of continuous sutures. The left atrial appendage is identified posterior to the aorta through the coronal junction of the transverse sinus and an atrial-clipping device advanced through the coronal junction of the transverse sinus. Once placed securely on the base of the left atrial appendage, it is clipped using an appropriately sized clip. The clip is released after visual confirmation of adequate placement and the left atrium inspected for hemostasis.
RESULTS: A right mini-anterolateral thoracotomy represents a less invasive option for mitral valve surgery without compromising the effectiveness of valve repair or patient safety. Atrial fibrillation is a risk factor for stroke and increases the lifetime risk in a patient, with 90% of embolic strokes originating from the left atrial appendage. Obliteration of the left atrial appendage in patients undergoing surgical treatment for atrial fibrilation or mitral valve regurgitation has been recommended. Conventional techniques of occlusion are not often utilized and possibly due to associated risks. The use of a clip device is preferred at our institution and has been implemented successfully using a right mini-anterolateral thoracotomy on multiple occasions.
CONCLUSIONS: When performing a right mini-anterolateral thoracotomy for mitral valve repair, clipping of the atrial appendage may prove beneficial to patients at risk for thromboembolic events. The accessibility of the left atrial appendage with a right mini-anterolateral thoracotomy and the relative ease of clip placement, makes this approach a feasible surgical option that has never before been described in conjunction with mitral valve repair. When compared to other surgical techniques, clipping may decrease the risk of complications and obliteration failure. In patients undergoing a right mini-anterolateral thoracotomy for mitral valve repair, the benefits of clipping the left atrial appendage should be considered.

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