INTRODUCTION Situs inversus totalis, dextrocardia with interrupted inferior vena cava and azygos vein continuation concomitant with symptomatic atrial fibrillation requiring ablation. This case was deemed not suitable for percutaneous ablation due to anatomic variations and the lack of case reports in literature. METHODS AND RESULTS We performed bilateral thoracoscopic epicardial ablation and epicardial left atrial appendage exclusion. The direct vision allowed for a complete box lesion set with bipolar radiofrequency device. Patient remained in sinus rhythm at 12-months follow-up. CONCLUSION Surgical thoracoscopic epicardial ablation is safe and effective also in congenital defects. Multidisciplinary expertise can offer minimally invasive ablation treatments.

Epicardial surgical clip is showed to be a safe and effective tool in order to achieve a complete left atrial appendage (LAA) exclusion thus reducing the risk of stroke in patients with atrial fibrillation. Historically, other methods as surgical ligation, internal oversewing or external stapling showed to be largely uneffective with an incidence of LAA residual flow ranging from 25% to 35% thus, increasing per se 5- to 10-fold the risk of stroke. Epicardial LAA exclusion by means of external clip could be potentially released under transesophageal echocardiographic guidance thus increasing the procedural success rate of complete closure with no residual stump left.

Atrial fibrillation (AF) is the most common atrial arrhythmia but it is not a benign disease. AF is an important risk factor for thromboembolic events, causing significant morbidity and mortality. The left atrial appendage (LAA) plays an important role in thrombus formation but the ideal way to manage the LAA is still debated. The increasing popularity of surgical epicardial ablation and hybrid endo-epicardial ablation approaches, especially in patients with a more advanced diseased substrate, has raised the interest in epicardial LAA management. Minimally invasive treatment options for the LAA offer a unique opportunity to close the LAA with a clip device. This review highlights morphologic, electrophysiologic and surgical aspects of the left atrial appendage with regard to atrial fibrillation surgery, and aims to illustrate the different surgical management strategies.