Totally Endoscopic Left Atrial Appendage Occlusion: The Role of 3D Printing in Preoperative Planning and Operative Steps

This video submission is from the 2025 CTSNet Innovation Video Competition. Watch all entries from the competition, including the winning videos.   

Atrial fibrillation (AFib) is the most common sustained arrhythmia encountered in clinical practice, and the left atrial appendage (LAA) is recognized as the predominant source of thromboembolic events in nonvalvular AFib . Therefore, left atrial appendage occlusion (LAAO) is an important adjunct in the management of AFib, particularly when combined with rhythm control procedures. In hybrid AFib convergent ablation, surgical access to the LAA provides an opportunity to achieve durable exclusion; however, optimal port positioning and exposure can be challenging due to variability in chest anatomy, LAA morphology, and the spatial relationships between the heart and chest wall. This can increase operative time and procedural complexity. 
 
In this video, the authors present an innovative, totally videoscopic technique for LAAO, enhanced by patient-specific 3D printing of the thoracic anatomy. This workflow began with preoperative cardiac CT acquisition and high-resolution segmentation to reconstruct the heart, chest wall, and LAA. A life-size 3D printed chest model was created, faithfully reproducing the patient’s anatomical configuration.  

This model allowed for precise identification of the LAA’s morphology, orientation, and its relationship to the rib spaces. Most important, it guided strategic port placement to optimize instrument access and avoid conflicts with the endoscopic arms.  
 
The patient was positioned laterally, with the left arm and shoulder supported in a caudal position to maximize intercostal exposure. Using the 3D model as a reference, ports were marked in a curvilinear configuration: the camera port at the fourth or fifth intercostal space (mid-axillary), the working port at the second to third intercostal space (hemiclavicular), and a secondary arm port at the sixth to seventh space. An optional utility port was triangulated to assist with pericardial retraction. 
 
After establishing dual-lumen ventilation, the pericardium was opened, exposing the LAA. The 3D printed model’s high-fidelity reproduction of LAA morphology helped confirm the true appendage base and facilitated clip sizing. The occlusion device was introduced and deployed under endoscopic visualization, ensuring complete exclusion. In selected cases, adjunctive cryo-nerve ablation of the intercostal nerves was performed for postoperative analgesia. 
 
The novelty of this technique lies in the integration of patient-specific 3D printed thoracic models into the planning and execution of totally videoscopic LAAO. This approach addresses a procedural gap by reducing anatomical uncertainty, shortening the learning curve, and enabling precise, reproducible port placement—factors that are especially important for centers adopting minimally invasive AFib surgery. The method is adaptable to varying anatomies and could enhance outcomes by improving exposure, reducing operative time, and potentially minimizing complications. 

This workflow complies with all established patient safety guidelines and is feasible within a standard hybrid AFib surgical program. The authors believe that the use of 3D printing as a preoperative adjunct will broaden the accessibility and reproducibility of minimally invasive LAAO and may serve as a platform for further innovation in image-guided cardiothoracic surgery.

References

1. Vukicevic M, Mosadegh B, Min JK, Little SH. Cardiac 3D Printing and Its Future Directions. JACC Cardiovasc Imaging. 2017;10(2):171-184. doi:10.1016/j.jcmg.2016.12.001

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