ABSTRACT
BACKGROUND: Historically, persistent atrial fibrillation (PeAF) and long standing persistent atrial fibrillation (LSPeAF) have demonstrated limited clinical success despite hybrid approaches. OBJECTIVE: We describe our experience with the endocardial-before-epicardial approach defined by a comprehensive endovascular approach preceding and guiding the epicardial approach which includes an extensive posterior wall ablation. METHODS: 40 patients were followed over a 12 month period. The procedure was performed in a single center. Patients had a mean duration of atrial fibrillation of 6.0 ± 4.5 years with 22.5% having undergone prior ablations. Mean age was 61.7 ± 7.9 years with a mean left atrial volume of 131.5 ± 46.9 mL. The endovascular procedure remained uniform with antral pulmonary vein isolation, posterior left atrial roof and right atrial cavo-tricuspid isthmus (CTI) linear lesions with mapping and ablation of left atrial complex electrograms (CFAEs) and prior existing atrial arrhythmias. The epicardial procedure included a thorascopic approach with ganglionated plexus (GP) mapping and ablation, left atrial posterior wall ablation, directed CFAE ablation and left atrial appendage ligation. All patients received implantable cardiac monitoring. RESULTS: All 40 patients remained in sinus rhythm at their 12 month follow-up. During the monitoring period, episodes of paroxysmal atrial arrhythmias including fibrillation were documented, without persistence, after discontinuation of oral antiarrhythmic medications. CONCLUSION: The endo-before-epi approach resulted in improved management of persistent and long standing persistent atrial fibrillation over reported results for conventional approaches with no procedural complications, making this a promising option for the management of these arrhythmias.
Subject(s)
Anti-Arrhythmia Agents/administration & dosage , Atrial Fibrillation/diagnosis , Atrial Fibrillation/surgery , Catheter Ablation/methods , Electrocardiography , Aged , Atrial Fibrillation/drug therapy , Catheter Ablation/adverse effects , Chronic Disease , Cohort Studies , Female , Follow-Up Studies , Humans , Infusions, Intravenous , Male , Middle Aged , Monitoring, Physiologic/methods , Preoperative Care/methods , Prospective Studies , Recurrence , Reoperation/methods , Risk Assessment , Severity of Illness Index , Time Factors , Treatment OutcomeABSTRACT
Here, we report intermediate follow-up details after using a technique of confluent posterior left atrial wall epicardial ablation designed to eliminate both existing and future atrial fibrillation (AF) substrates. The method is part of the Convergent hybrid procedure for AF ablation. In this study, multiple confluent epicardial ablations with radiofrequency energy were delivered, spanning the vertical and transverse dimensions of the posterior left atrium, along with facilitated pulmonary vein isolation (PVI). Endocardial mapping and ablation were performed to complete PVI and to ablate the cavotricuspid isthmus. All patients were followed clinically and using two-to-four weeks of continuous monitoring at six, 12, and 24 months, respectively. The average length of follow-up was 488 days. Of the 57 largely unselected patients with persistent or longstanding persistent AF (NPAF), mean duration of AF was 5.6 years. Single procedure freedom from AF through 24 months was 64.5%, and that for all arrhythmias, was 58.9%. Sixty-eight percent of patients were off antiarrhythmic drugs. Four patients (7%) required a second endocardial ablation procedure. A sub-analysis of the observed arrhythmia burden present through follow-up showed this to be small (ie, <1%) in the majority of patients involved in this study. In conclusion, the extended posterior left atrial wall ablation technique discussed here, as part of the Convergent hybrid method, achieved notable single-procedure success in a particularly challenging series of patients with NPAF.
