Minimally Invasive Surgical Strategies for the Treatment of Atrial Fibrillation: An Evolving Role in Contemporary Cardiac Surgery

Atrial fibrillation remains the most frequent sustained arrhythmia, particularly in the elderly population, and is associated with increased risks of stroke, heart failure, and reduced quality of life. While catheter ablation is widely used for rhythm control, its efficacy is limited in persistent and long-standing atrial fibrillation. Over the past two decades, minimally invasive surgical strategies have emerged as effective alternatives, aiming to replicate the success of the Cox-Maze procedure while reducing surgical trauma. This overview critically summarizes the current minimally invasive techniques available for atrial fibrillation treatment, including mini-thoracotomy ablation, thoracoscopic ablation, and hybrid procedures such as the convergent approach. These methods offer the potential for durable sinus rhythm restoration by enabling direct visualization, transmural lesion creation, and left atrial appendage exclusion, with lower perioperative morbidity compared to traditional open surgery. The choice of energy source plays a key role in lesion efficacy and safety. Particular attention is given to the technical steps of each procedure, patient selection criteria, and the role of left atrial appendage closure in stroke prevention. Hybrid strategies, which combine epicardial surgical ablation with endocardial catheter-based procedures, have shown encouraging outcomes in patients with refractory or long-standing atrial fibrillation. Despite the steep learning curve, minimally invasive techniques provide significant benefits in terms of recovery time, reduced hospital stay, and fewer complications. As evidence continues to evolve, these approaches represent a key advancement in the surgical management of atrial fibrillation, deserving integration into contemporary treatment algorithms and multidisciplinary heart team planning.