Device Implantation
LAA occlusion through the epicardial pathway, which was video-assisted thoracoscopic surgery (VATS), was as follows (Figure 1). The patient lied supine on the operating table with the middle of the chest raised. Firstly, the surgical bed was rotated to the left, and a 1 cm operation hole was opened at the front of the fourth intercostal axillary line. Under the condition of ventilation of the left lung, the pericardium was opened, and the right pulmonary veins were dissociated. The right pulmonary veins were electrically isolated by radiofrequency ablation. Then the surgical bed shaked to the right, after a 3cm left incision at the intercostal midline was made, the left pleura was opened, and the right lung was ventilated separately. Then the pericardium was opened, the Marshall ligament was cut, and the left pulmonary veins were electrically isolated. Afterwards, the LAA was sewn with two purse-string sutures and a 12F transport sheath was placed in the middle of the sutures. Under the guidance of TEE, the occluding plate of the occluder was released in the left atrium and pulled back until the opening of the LAA was completely covered. At this time, the fixing plate of the occluder was released. After 2D and 3D TEE showed that there was almost no residual blood flow in the LAA, the transmission cable and sheath were withdrawn when the occluder device was in a good position.