Atrial fibrillation is the most common sustained arrhythmia and is associated with significant risks of thromboembolism, stroke, congestive heart failure, and death. There have been major advances in the management of atrial fibrillation including pharmacologic therapies, antithrombotic therapies, and ablation techniques. Surgery for atrial fibrillation, including both concomitant and stand-alone interventions, is an effective therapy to restore sinus rhythm. Minimally invasive surgical ablation is an emerging field that aims for the superior results of the traditional Cox-Maze procedure through a less invasive operation with lower morbidity, quicker recovery, and improved patient satisfaction. These novel techniques utilize endoscopic or minithoracotomy approaches with various energy sources to achieve electrical isolation of the pulmonary veins in addition to other ablation lines. We review advancements in minimally invasive techniques for atrial fibrillation surgery, including management of the left atrial appendage. 1. Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting over 2 million people in the United States [1]. The lifetime risks for developing AF are 1 in 6, even in those without previous cardiac disease and as high as 1 in 4 in those individuals older than 40 years [2]. It is associated with nearly a five-fold increased risk of stroke and over two-fold increase risk of death [3]. There have been many advances in the management of AF including pharmacological therapies, antithrombotic therapies, and ablation techniques. Concurrently, minimally invasive cardiac surgery techniques have emerged to treat selected patients with AF, refractory to medical therapy, with surgical ablation and left atrial appendage (LAA) resection through much smaller, sternal sparing incisions. These innovative techniques focus on pulmonary vein isolation, ablation of the left atrial isthmus and right atrial isthmus in addition to other ablation lines and can be performed as either a stand-alone operation or concomitant with another minimally invasive cardiac operation. The goals of minimally invasive AF surgeries are to achieve the same success in restoring sinus rhythm as the conventional Cox-Maze procedure with a more cosmetically appealing incision, quicker recovery, and improved patient, satisfaction. 2. History of AF Surgery It has been recognized that in patients with chronic AF, pharmacological rhythm control is ineffective in half of patients, and electrical cardioversion has high recurrence rates [4, 5]. As a result,
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