Hybrid Procedure (Endo/Epicardial) versus Standard Manual Ablation in Patients Undergoing Ablation of Longstanding Persistent Atrial Fibrillation: Results from a Single Center

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Model for predicting the recurrence of atrial fibrillation after monopolar or bipolar radiofrequency ablation in patients with AF and mitral valve disease

OBJECTIVES

This study aimed to identify the risk factors for postoperative atrial fibrillation in patients with valvular atrial fibrillation, and establish predictive models of atrial fibrillation recurrence.

METHODS

Overall, 224 patients who underwent radiofrequency ablation of atrial fibrillation from November 2014 to November 2020 were included. The statistical package for social sciences, X-tile, and R-studio were used for statistical analysis.

RESULTS

Patients were divided into training and validation sets according to a ratio of 3:1. The training set was analysed using univariate and multivariate Cox regression analysis and showed that preoperative uric acid > 401 μmol/L (P = 0.006), B-type natriuretic peptide > 202 ng/L (P = 0.042), hypersensitivity C-reactive protein > 6.1 mg/L (P = 0.026), erythrocyte sedimentation rate > 7.0 mm/h (P = 0.016), preoperative left atrial diameter > 48 mm (P = 0.031) were significantly correlated with the recurrence of atrial fibrillation after radiofrequency ablation in patients with valvular atrial fibrillation. In the training set, a Cox regression model of the five related factors was established using the R language. The C-index of the model was 0.82, and the area under the receiver operating characteristic curve was 0.831 (P < 0.001). Internal and external verification was performed in the training and validation sets, respectively, and both showed that the fit of the verification curve was relatively good at 3 months, 6 months, 1 year, and 3 years postoperatively. After calculating the weight of each related factor using the nomogram, a new risk predictive model (BLUCE) for postoperative atrial fibrillation was established.

CONCLUSIONS

In patients with atrial fibrillation, preoperative uric acid, B-type natriuretic peptide, hypersensitivity C-reactive protein, erythrocyte sedimentation rate, and left atrial diameter are risk factors for atrial fibrillation or atrial flutter recurrence after radiofrequency ablation. The BLUCE predictive model can distinguish high-risk groups of postoperative atrial fibrillation. High-risk patients in the BLUCE model were more likely to experience recurrence of atrial fibrillation after radiofrequency ablation and a low possibility of maintaining sinus rhythm.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Mid term freedom from atrial fibrillation following hybrid ablation, a systematic review and meta analysis

INTRODUCTION

Atrial Fibrillation (AF) is a common tachyarrhythmia affecting 33 million people worldwide. Hybrid AF ablation utilises a surgical (epicardial) ablation followed by an endocardial catheter-based ablation. The aim of this systematic review and meta-analysis is to summarize the literature reporting mid-term freedom from AF following hybrid ablation.

METHODS

An electronic search of databases was performed to identify all relevant studies providing mid-term (2 year) outcomes following hybrid ablation for AF. The primary study outcome was to assess the mid-term freedom from AF following hybrid ablation, utilising the metaprop function on Stata® (Version 17.0, StataCorp, Texas, USA). Subgroup analysis was performed to assess the impact of various operative characteristics on mid-term freedom from AF. The secondary outcomes assessed mortality and procedural complication rate.

RESULTS

The search strategy identified 16 studies qualifying for inclusion in this meta-analysis, with 1242 patients in total. The majority of papers were retrospective cohort studies (15) and one study was a randomized control trial (RCT). The mean follow up was 31.5 ± 8.4 months. Following hybrid ablation, the overall mid-term freedom from AF was 74.6% and 65.4% for patients off antiarrhythmic drugs (AAD). Actuarial freedom from AF was 78.2%, 74.2% and 73.6% at 1, 2 and 3 years respectively. No significant differences in mid-term freedom from AF based epicardial lesion set (box vs pulmonary vein isolation) or Left atrial appendage/Ganglionated Plexus/Ligament of Marshall ablation or staged vs concomitant procedures. There were 12 deaths overall following the hybrid procedure with a pooled complication rate of 5.53%.

CONCLUSION

Hybrid AF ablation offers promising mid-term freedom from AF reported at a mean follow-up of 31.5 months. The overall complication rate remains low. Further analysis of high-quality studies with randomized data and long-term follow up will help verify these results.

Rhythm outcomes of minimally-invasive off-pump surgical versus catheter ablation in atrial fibrillation: A meta-analysis of reconstructed time-to-event data

BACKGROUND

Mid- and long-term rhythm outcomes of catheter ablation (CA) for atrial fibrillation (AF) are reported to be suboptimal. Minimally invasive surgical off-pump ablation (MISOA), including both thoracoscopic and trans-diaphragmatic approaches, has been developed to reduce surgical invasiveness and overcome on-pump surgery drawbacks. We sought to compare the efficacy and safety of MISOA and CA for AF treatment.

METHODS

A systematic review and meta-analysis of the literature was performed including studies comparing MISOA and CA. The primary endpoint was survival freedom from AF at follow-up after a 3-month blanking period. Subgroup analysis of the primary endpoint was performed according to the type of surgical incision and hybrid approach.

RESULTS

Freedom from AF at 4 years was 52.1% ± 3.2% vs 29.1% ± 3.5%, between MISOA and CA respectively (log-rank p < 0.001; Hazard Ratio: 0.60 [95%Confidence Interval (CI):0.50-0.72], p < 0.001). At landmark analysis, a significant improvement in rhythm outcomes was observed in the MISOA group after the 5th month of follow-up (2 months from the blanking period). The Odds Ratio between MISOA and CA of postoperative cerebrovascular accident incidence and postoperative permanent pacemaker implant (PPM) were 2.00 (95%CI:0.91-4.40, p = 0.084) and 1.55 (95%CI:0.61-3.95, p = 0.358), respectively. The incidence rate ratio of late CVA between MISOA and CA was 0.86 (95%CI:0.28-2.65, p = 0.787), while for late PPM implant was 0.45 (95%CI:0.11-1.78, p = 0.256).

CONCLUSIONS

The current meta-analysis suggests that MISOA provides superior rhythm outcomes when compared to CA in terms of sinus rhythm restoration. Despite the rhythm outcome superiority of MISOA, it is associated to higher postoperative complications compared to CA.

Hybrid epicardial-endocardial ablation for long-standing persistent atrial fibrillation: A subanalysis of the CONVERGE Trial

Background

Favorable clinical outcomes are difficult to achieve in long-standing persistent atrial fibrillation (LSPAF) with catheter ablation (CA). The CONVERGE (Convergence of Epicardial and Endocardial Ablation for the Treatment of Symptomatic Persistent Atrial FIbrillation) trial evaluated the effectiveness of hybrid convergent (HC) ablation vs endocardial CA.

Objective

The study sought to evaluate the safety and effectiveness of HC vs CA in the LSPAF subgroup from the CONVERGE trial.

Methods

The CONVERGE trial was a prospective, multicenter, randomized trial that enrolled 153 patients at 27 sites. A post hoc analysis was performed on LSPAF patients. The primary effectiveness was freedom from atrial arrhythmias off new or increased dose of previously failed or intolerant antiarrhythmic drugs (AADs) through 12 months. The primary safety endpoint was major adverse event incidence through 30 days with HC. Key secondary effectiveness measures included (1) percent of patients achieving ≥90% AF burden reduction vs baseline and (2) AF freedom.

Results

Sixty-five patients (42.5% of total enrollment) had LSPAF; 38 in HC and 27 in CA. Primary effectiveness was 65.8% (95% confidence interval [CI] 50.7%-80.9%) with HC vs 37.0% (95% CI 5.1%-52.4%) with CA (P = .022). Through 18 months, these rates were 60.5% (95% CI 50.0%-76.1%) with HC vs 25.9% (95% CI 9.4%-42.5%) with CA (P = .006). Secondary effectiveness rates were higher than CA with HC at 12 and 18 months. Freedom from atrial arrhythmias off AADs was 52.6% (95% CI 36.8%-68.5%) and 47.4% (95% CI 31.5%-63.2%) with HC at 12 and 18 months vs 25.9% (95% CI 9.4%-42.5%) and 22.2% (95% CI 6.5%-37.9%) with CA, respectively (12 months: P = .031; 18 months: P = .038). Three (7.9%) major adverse events occurred within 30 days of HC.

Conclusion

Post hoc analysis demonstrated effectiveness and acceptable safety of HC compared with CA in LSPAF.

Assessing the impact of blocking distal coronary sinus-left atrial muscular connection on inducible rate of atrial fibrillation and follow-up recurrence in persistent atrial fibrillation patients with different fibrotic degrees of left atrial: A retrospective study

Background

The musculature of the coronary sinus (CS), especially its distal connection with the post wall of the left atrial (LA), has been associated with the genesis and maintenance of atrial flutter (AFL) and atrial fibrillation (AF). However, the relative contributions of the distal coronary sinus (CSD)-LA connection to PersAF with various degrees of atrial fibrosis remain unknown.

Objective

This study aimed to explore the different roles of blocking the CSD-LA connection in the induction of acute AF and middle-term follow-up of recurrence among PersAF patients with various degrees of LA fibrosis.

Methods and results

A retrospective cohort of 71 patients with drug-refractory and symptomatic PersAF underwent ablation for the first time were studied. The population was divided into two groups according to disconnection of the CSD-LA or not. All patients enrolled accepted the unified ablation procedure (circumferential pulmonary vein isolation, non-pulmonary vein trigger ablation and ablation of the CSD-LA connection). Group A (n = 47) successfully blocked the CSD-LA electrical connection and Group B (n = 24) failed. Twenty-five patients could be induced into sustained AF in the Group A compared to 20 in the Group B (53.2 vs. 83.3%, p = 0.013). After a mean follow-up of 185 ± 8 days, 24 (33.8%) patients experienced atrial arrhythmia recurrences. The Group A had significantly fewer recurrences (25.5%) compared to Group B (50%). Meanwhile, in Group A, the ROC curve analysis suggested that in the case of blocking CSD-LA, low voltage area (LVA) of LA can act as a predictive factor for acute AF induction (AUC = 0.943, Cut-off = 0.190, P < 0.001) with sensitivity and specificity of 92.3 and 90.5%, and middle-term recurrence (AUC = 0.889, Cut-off = 0.196, P < 0.001) with sensitivity and specificity of 100 and 65.7%.

Conclusion

Disconnection of CSD-LA could reduce the inducible rate of acute AF and the recurrences of atrial arrhythmia during middle-term follow-up. The PersAF patients with CSD-LA muscular connection blocked, experienced a higher acute AF inducible rate with larger proportion of LVA of LA (≥19%) and a higher recurrent rate of atrial arrhythmias with a larger proportion of LA fibrosis (≥19.6%).

Detection of endo-epicardial atrial low-voltage areas using unipolar and omnipolar voltage mapping

Background: Low-voltage areas (LVA) can be located exclusively at either the endocardium or epicardium. This has only been demonstrated for bipolar voltages, but the value of unipolar and omnipolar voltages recorded from either the endocardium and epicardium in predicting LVAs at the opposite layer remains unknown. The goal of this study was therefore to compare simultaneously recorded endo-epicardial unipolar and omnipolar potentials and to determine whether their voltage characteristics are predictive for opposite LVAs.

Methods: Intra-operative simultaneous endo-epicardial mapping (256 electrodes, interelectrode distances 2 mm) was performed during sinus rhythm at the right atrium in 93 patients (67 ± 9 years, 73 male). Cliques of four electrodes (2 × 2 mm) were used to define maximal omnipolar (Vomni,max) and unipolar (Vuni,max) voltages. LVAs were defined as Vomni,max ≤0.5 mV or Vuni,max ≤1.0 mV.

Results: The majority of both unipolar and omnipolar LVAs were located at only the endocardium (74.2% and 82.0% respectively) or epicardium (52.7% and 47.6% respectively). Of the endocardial unipolar LVAs, 25.8% were also located at the opposite layer and 47.3% vice-versa. In omnipolar LVAs, 18.0% of the endocardial LVAs were also located at the epicardium and 52.4% vice-versa. The combination of epicardial Vuni,max and Vomni,max was most accurate in identifying dual-layer LVAs (50.4%).

Conclusion: Unipolar and omnipolar LVAs are frequently located exclusively at either the endocardium or epicardium. Endo-epicardial LVAs are most accurately identified using combined epicardial unipolar and omnipolar voltages. Therefore, a combined endo-epicardial unipolar and omnipolar mapping approach is favoured as it may be more indicative of possible arrhythmogenic substrates.

The Convergent Ablation and AtriClip Exclusion of the Left Atrial Appendage in Long-Standing Persistent Atrial Fibrillation

We here present a case of a 54-year-old man with longstanding persistent atrial fibrillation refractory to direct current electrical cardioversion who underwent a concurrent convergent ablation and Atriclip exclusion of left atrial appendage. His preoperative echocardiography revealed dilated 5.8 cm left atrium with a normal left ventricular ejection fraction of 50%. Transmural isolation of pulmonary veins was performed through a subxiphoid approach, and 3 left-sided video-assisted thoracoscopic surgery ports were utilised to occlude the base of the left atrium appendage with the Atriclip device. A peri-operative transoesophageal echocardiogram confirmed left atrium appendage base occlusion, and the patient was in sinus rhythm after having a single 200 kJ direct current cardioversion shock. The postoperative period was uneventful, and the patient was discharged with preprocedural anticoagulant after 24 hours of the procedure and advised to come for follow up after 3 months.

Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: a systematic review and meta-analysis of randomised control trials and propensity matched studies

INTRODUCTION

Atrial fibrillation (AF) is the most common arrhythmia. Hybrid convergent ablation (HCA) is an emerging procedure for treating longstanding AF with promising results. HCA consists of a subxiphoid, surgical ablation followed by completion endocardial ablation. This meta-analysis of randomized control trials (RCT's) and propensity score-matched studies aims to examine the efficacy and safety of HCA compared to endocardial catheter ablation (ECA) alone on patients with AF.

METHODS

This review was written in accordance with preferred reporting items for systematic reviews and meta-analyses recommendations and guidance. The primary outcome for the analysis was freedom from AF (FFAF) at final follow up. Secondary outcomes were mortality and significant complications such as tamponade, sternotomy, esophageal injury, atrio-esophageal fistulae post procedurally.

RESULTS

Four studies where included, with a total of 233 patients undergoing HCA and 189 patients undergoing ECA only. Pooled analysis demonstrated that HCA cohorts had significantly higher rates of FFAF than ECA cohorts, with an OR of 2.78 (95% CI 1.82-4.24, P < 0.01, I2 = 0). Major post-operative complications were observed in significantly more patients in the HCA group, with an OR of 5.14 (95% CI 1.70-15.54, P < 0.01). There was only one death reported in the HCA cohorts, with no deaths in the ECA cohort.

CONCLUSION

HCA is associated with a significantly higher FFAF than ECA, however, it is associated with increased post-procedural complications. There was only one death in the HCA cohort. Large RCT's comparing the HCA and ECA techniques may further validate these results.

A Chronicle of Hybrid Atrial Fibrillation Ablation Therapy: From Cox Maze to Convergent

The burden of AF is increasing in prevalence and healthcare resource usage in the UK and worldwide. It can result in impaired quality of life for affected patients, as well as increased risk of stroke, heart failure and mortality. A holistic, integrated approach to AF management is recommended, which may include a focus on reducing risk factors and on medical management with anticoagulation and anti-arrhythmic drugs. There are also various ablation strategies that may be considered when anti-arrhythmic drugs fail to alleviate symptoms and reduce AF burden. These ablation techniques range from standalone percutaneous endocardial catheter ablation to open surgical ablation procedures concomitant with cardiac surgery. More recently, hybrid ablation that combines aspects of both surgical and electrophysiologically targeted ablation has been described. This article reviews the evolution of ablation strategies, beginning with the origin of the Cox maze IV procedure and continuing to the recent hybrid convergent approach, and provides a summary of the associated outcomes.

Mapping Atrial Fibrillation After Surgical Therapy to Guide Endocardial Ablation

BACKGROUND

Surgical ablation for atrial fibrillation (AF) can be effective, yet has mixed results. It is unclear which endocardial lesions delivered as part of hybrid therapy' will best augment surgical lesion sets in individual patients. We addressed this question by systematically mapping AF endocardially after surgical ablation and relating findings to early recurrence, then performing tailored endocardial ablation as part of hybrid therapy.

METHODS

We studied 81 consecutive patients undergoing epicardial surgical ablation (stage 1 hybrid), of whom 64 proceeded to endocardial catheter mapping and ablation (stage 2). Stage 2 comprised high-density mapping of pulmonary vein (PV) or posterior wall (PW) reconnections, low-voltage zones (LVZs), and potential localized AF drivers. We related findings to postsurgical recurrence of AF.

RESULTS

Mapping at stage 2 revealed PW isolation reconnection in 59.4%, PV isolation reconnection in 28.1%, and LVZ in 42.2% of patients. Postsurgical recurrence of AF occurred in 36 patients (56.3%), particularly those with long-standing persistent AF (P=0.017), but had no relationship to reconnection of PVs (P=0.53) or PW isolation (P=0.75) when compared with those without postsurgical recurrence of AF. LVZs were more common in patients with postsurgical recurrence of AF (P=0.002), long-standing persistent AF (P=0.002), advanced age (P=0.03), and elevated CHA2DS2-VASc (P=0.046). AF mapping revealed 4.4±2.7 localized focal/rotational sites near and also remote from PV or PW reconnection. After ablation at patient-specific targets, arrhythmia freedom at 1 year was 81.0% including and 73.0% excluding previously ineffective antiarrhythmic medications.

CONCLUSIONS

After surgical ablation, AF may recur by several modes particularly related to localized mechanisms near low voltage zones, recovery of posterior wall or pulmonary vein isolation, or other sustaining mechanisms. LVZs are more common in patients at high clinical risk for recurrence. Patient-specific targeting of these mechanisms yields excellent long-term outcomes from hybrid ablation.

Hybrid ablation procedure for the treatment of nonparoxysmal atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

Hybrid ablation combines the advantages of surgical and catheter ablation. Many studies have explored the efficiency and safety of hybrid ablation in patients with nonparoxysmal AF.

METHODS

We systematically searched for prospective controlled trials that compared hybrid ablation with catheter/surgical ablation in PubMed, Web of Science, Wiley Library and CNKI. Our main assessment indicators included maintenance of sinus rhythm without antiarrhythmic drugs for more than 12 months, major adverse events (MAEs), procedure time and fluoroscopy time.

RESULTS

Of 1214 identified studies, 5 were eligible and were included in our analysis (N = 451 participants). The pooled results showed that hybrid ablation was more effective in maintaining SR than a single procedure (surgical ablation or catheter ablation) (OR = 2.52, 95% confidence interval [CI]: 1.63-3.89, P<0.001). Little significant heterogeneity was revealed (P = 0.32 for heterogeneity, I² = 14%). More MAEs occurred in the hybrid group than in the single procedure group (OR = 7.47, 95% CI: 1.90-29.41, P = 0.004; I² = 0%). Two trials reported the procedure and fluoroscopy times, and the procedure time for hybrid ablation was significantly longer than that of a single procedure (mean difference = 107.42, 95% CI: 88.62 to 126.22, P < 0.001; I² = 82%). There was no significant difference in fluoroscopy time between the 2 groups (mean difference = -1.00, 95% CI: -5.37 to 3.36, P = 0.65; I² = 12%).

CONCLUSIONS

Hybrid ablation was more effective than catheter ablation and was as effective as surgical ablation in patients with nonparoxysmal AF. Meanwhile, hybrid ablation, especially concomitant hybrid ablation, increases the incidence of MAEs and prolongs the procedure time. This article is protected by copyright. All rights reserved.

Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: A systematic review and meta-analysis

INTRODUCTION

Endocardial catheter ablation (ECA) for atrial fibrillation (AF) has limited efficacy. Hybrid convergent procedure (HCP) with both epicardial and endocardial ablation is a novel strategy for AF treatment. In this meta-analysis, we aimed to evaluate the efficacy and safety of HCP in AF ablation.

METHOD

We performed a comprehensive literature search for studies that evaluated the efficacy and safety of HCP compared with ECA for AF. The primary outcome was freedom of atrial arrhythmia (AA). The secondary outcome was the periprocedural complication rate. Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated using the random effects model.

RESULTS

A total of eight studies, including 797 AF patients (mean age: 60.7 ± 9.8 years, 366 patients with HCP vs. 431 patients with ECA alone), were included. HCP showed a higher rate of freedom of AA compared with ECA (RR: 1.48, 95% CI: 1.13-1.94, p = .004). However, HCP was associated with higher rates of periprocedural complications (RR: 3.64, 95% CI: 2.06-6.43; p = .00001). Moreover, the HCP had a longer procedure time and postprocedural hospital stay.

CONCLUSIONS

Although hybrid ablation was associated with a higher success rate, this should be judged for increased periprocedural adverse events and extended hospital stay. Prospective large-scale randomized trials are needed to validate these results.

Hybrid ablation for atrial fibrillation: A systematic review and meta-analysis

Background

Both catheter and surgical ablation strategies offer effective treatments of atrial fibrillation (AF). The hybrid (joint surgical and catheter) ablation for AF is an emerging rhythm control strategy. We sought to determine the efficacy and safety of hybrid ablation of AF.

Methods

Systematic review and meta-analysis interrogating PubMed, EMBASE, and Cochrane databases from January 1, 1991, to November 30, 2017, using the following search terms: “Cox-maze,” “mini-maze,” “ablation methods (including radiofrequency, cryoablation, cryomaze),” and “surgery.” Included studies required ablation procedures to be hybrid and report rhythm follow-up.

Results

We included 925 patients with AF (38% persistent, 51% longstanding persistent) from 22 single-center studies (mean follow-up of 19 months). The surgical lesion set consisted of pulmonary vein isolation (n = 11) or box lesion (n = 11) with variable additional linear ablation. This was followed by sequential (n = 9), staged (n = 9), or combination (n = 4) catheter-based ablation to ensure isolation of pulmonary veins and to facilitate additional ablation or consolidation of surgically ablated lines. Overall, sinus rhythm maintenance was 79.4% (95% confidence interval [CI], 72.4-85.7] and 70.7% (95% CI, 62.2-78.7) with and without antiarrhythmic drugs, respectively at 19 ± 25 (range, 6-128) months. The use of the bipolar AtriCure Synergy system and left atrial appendage exclusion conferred superior rhythm outcome without antiarrhythmic drugs (P ≤ .01). The overall complication rate was 6.5% (95% CI, 3.4-10.2): mortality 0.2% (95% CI, 0-0.9); stroke 0.3% (95% CI, 0-1.1); reoperation for bleeding 1.6% (95% CI, 0.6-3.0); permanent pacing ~0% (95% CI, 0-0.5); conversion to sternotomy 0.3% (95% CI, 0-1.1); atrioesophageal fistula ~0% (95% CI, 0-0.5); and phrenic nerve injury 0.3% (95% CI, 0-1.1).

Conclusions

Hybrid ablation therapy for AF demonstrates favorable rhythm outcome with acceptable complication rates.

Intraprocedural arrhythmia termination as an end point for hybrid ablation in patients with long-standing persistent atrial fibrillation: a 2-year follow-up study

OBJECTIVES

Hybrid catheter and surgical ablation has emerged as an effective therapy for patients with persistent atrial fibrillation (AF). The aims of this study were to evaluate the relationship between intraprocedural arrhythmia termination and the long-term outcomes of hybrid ablation in patients with long-standing persistent AF.

METHODS

From May 2015 through April 2019, 50 patients with persistent AF with a mean duration of 73.3 ± 62.1 (median 54) months underwent single-step hybrid ablation. Pulmonary vein isolation, left atrial posterior wall isolation and left atrial appendage excision or closure were performed through a left-sided thoracoscopic approach. Subsequently, all patients underwent high-density endocardial mapping and electrogram-based ablation with the end point of AF termination.

RESULTS

We achieved intraprocedural AF termination in 84% (42/50) patients; this end point was reached in 16 patients during surgical ablation and in 26 patients during catheter ablation. Seven patients underwent repeat catheter ablation. After a mean follow-up period of 29 ± 13 months, the freedom from atrial tachyarrhythmia of a single procedure without the use of antiarrhythmic drugs was 70% (35/50). In the Cox regression model, intraprocedural termination of AF (hazard ratio 0.205, 95% confidence interval 0.058-0.730; P = 0.014) was the sole predictor of success.

CONCLUSIONS

The 2-year outcomes of a one-stop hybrid ablation with an end point of AF termination are promising in patients with long-standing persistent AF.

Subxiphoid Hybrid Epicardial-Endocardial Atrial Fibrillation Ablation and LAA Ligation: Initial Sub-X Hybrid MAZE Registry Results

OBJECTIVES

The aim of this study was to assess the safety and efficacy of a new subxiphoid hybrid epicardial-endocardial atrial fibrillation (AF) ablation and left atrial appendage (LAA) ligation approach for the treatment of persistent AF.

BACKGROUND

Surgical hybrid ablation procedures have shown promise for maintaining sinus rhythm versus catheter ablation but are associated with increased periprocedural adverse events.

METHODS

Patients with symptomatic persistent AF (n = 33, mean age 64 ± 9 years, 25 men) who had antiarrhythmic drug therapy or prior catheter ablation was unsuccessful were referred for hybrid epicardial-endocardial AF ablation and LAA exclusion. LAA closure was confirmed by transesophageal echocardiographic Doppler flow and/or computed tomographic angiography 1 to 3 months post-ligation. The incidence of atrial tachycardia or AF recurrence, LAA closure, thromboembolic events, and post-operative complications were assessed.

RESULTS

All 33 patients underwent successful LAA ligation with epicardial ablation of the posterior left atrial wall, as well as endocardial pulmonary vein isolation and cavotricuspid isthmus ablation. Freedom from atrial tachycardia or AF was 91% (20 of 22 patients) at 6 months, 90% (18 of 20 patients) at 12 months, 92% (11 of 12 patients) at 18 months, and 92% (11 of 12) at 24 months. There were no acute periprocedural complications (<7 days). Thirty-day adverse events included 2 patients with pericardial effusion requiring pericardiocentesis and 1 incisional hernia repair. There were no long-term complications, strokes, or deaths. LAA ligation was complete in 27 of 33 subjects (82%), with 6 subjects having leaks of <5 mm.

CONCLUSIONS

Subxiphoid hybrid epicardial-endocardial ablation with LAA ligation is feasible, safe, and effective. Future prospective studies are needed to validate these initial findings.

The Convergent Atrial Fibrillation Ablation Procedure: Evolution of a Multidisciplinary Approach to Atrial Fibrillation Management

The treatment of AF has evolved over the past decade with increasing use of catheter ablation in patients refractory to medical therapy. While pulmonary vein isolation using endocardial catheter ablation has been successful in paroxysmal AF, the results have been more controversial in patients with long-standing persistent AF where extrapulmonary venous foci are increasingly recognised in the initiation and maintenance of AF. Hybrid ablation is the integration of minimally invasive epicardial ablation with endocardial catheter ablation, and has been increasingly used in this population with better results. The aim of this article was to analyse and discuss the evidence for the integration of catheter and minimally invasive surgical approaches to treat AF with specific focus on convergent ablation and exclusion of the left atrial appendage using a surgically applied clip.

The Convergent Procedure: A Unique Multidisciplinary Hybrid Treatment of Atrial Fibrillation

The convergent procedure is a hybrid ablation treatment for atrial fibrillation. It is increasingly considered as a management option for patients with persistent and long-standing atrial fibrillation. It consists of surgical ablation of the posterior left atrium through a minimally invasive closed-chest approach followed by endocardial catheter ablation. It is increasingly performed with concurrent epicardial occlusion of the left atrial appendage with a video-assisted thoracoscopic technique to physically and electrically isolate the left atrial appendage. This article provides an overview of a multidisciplinary approach to the convergent procedure, with concurrent thoracoscopic closure of the left atrial appendage, with an emphasis on perioperative management at a single institution. It provides a literature review of procedural outcomes, current data limitations, and future considerations.

The Role of the Electrophysiologist in Convergent Ablation

Catheter ablation is a well-established treatment for patients with AF in whom sinus rhythm is desired. Both radiofrequency catheter ablation and cryoablation are widely performed, rapidly developing techniques. Convergent ablation is a novel hybrid technique combining an endocardial radiofrequency ablation with a minimally invasive epicardial surgical ablation. Some suggest that hybrid ablation may be more effective than lone endocardial ablation in achieving the elusive goal of maintaining sinus rhythm in patients with non-paroxysmal AF. In this article, the authors examine the safety and efficacy of catheter ablation and convergent ablation for long-standing, persistent AF. We also outline the crucial role that electrophysiologists play, not only as a procedure operator, but also as the coordinator and developer of this multidisciplinary service.

Catheter ablation is preferred over surgery for persistent atrial fibrillation

There are important limitations that can hinder outcomes of surgical ablation in nonparoxysmal patients with atrial fibrillation (AF), which is the typical AF population undergoing concomitant cardiac surgery for valve or ischemic heart disease. Incomplete lesions with recovered conduction or gaps as well as arrhythmias originating from areas not targeted by surgical ablation are commonly seen at the time of recurrence. Therefore, while it might be reasonable to perform AF surgery in this cohort, it is important to know these limitations and establish adequate postoperative rhythm monitoring to detect recurrences, which can be effectively addressed by catheter ablation.

Radiofrequency-Assisted Transseptal Access for Atrial Fibrillation Ablation Via a Superior Approach

OBJECTIVES

This study describes the technique and outcomes of atrial fibrillation (AF) ablation via a superior approach in patients with interrupted or absent inferior vena cavas (IVCs).

BACKGROUND

In patients with interrupted or absent IVCs, transseptal access cannot be obtained via standard femoral venous access. In these patients, alternative strategies are necessary to permit catheter ablation in the left atrium (LA). This study reports on the outcomes of AF ablation from a superior venous access with a radiofrequency (RF)-assisted transseptal puncture (TSP) technique.

METHODS

This study identified patients with interrupted or absent IVCs who underwent AF ablation via a superior approach at 2 ablation centers from 2010 to 2019.

RESULTS

Fifteen patients (mean age: 50.8 ± 11.2 years; 10 men; 10 with paroxysmal AF) with interrupted or absent IVCs underwent AF ablation with transseptal access via a superior approach. Successful TSP was performed either with a manually bent RF transseptal needle (early cases: n = 4) or using a RF wire (late cases: n = 11); this approach permitted LA mapping and ablation in all patients. Mean time required to perform single (n = 8) or double (n = 7) TSP was 16.1 ± 4.8 min, and mean total procedure time was 227.9 ± 120.7 min (fluoroscopy time: 57.0 ± 28.5 min). LA mapping and ablation were successfully performed in all patients.

CONCLUSIONS

In patients with AF undergoing catheter ablation and who had a standard transseptal approach via femoral venous approach is impossible due to anatomic constraints, RF-assisted transseptal access via a superior approach can be an effective alternative strategy to permit LA mapping and ablation.

The relationship between red blood cell distribution width and atrial fibrillation in Asian population: A cross-sectional study

BACKGROUND

Red blood cell distribution width (RDW) was related with increased risk of mortality and adverse cardiovascular outcomes. However, it is uncertain whether RDW is related to the prevalence of atrial fibrillation (AF) in Asian population. The aim of this study was to assess the relationship between RDW and AF in a large Chinese population.

METHODS

We performed a cross-sectional study to examine the relationship between RDW and AF among 106 998 subjects who were from the Tianjin Chronic Low-grade Systemic Inflammation and Health Cohort Study. AF was diagnosed using electrocardiography, and RDW was measured using an automated hematology analyzer. Multiple logistic regression models were conducted to examine the relation between tertiles of RDW and AF.

RESULTS

The overall prevalence of AF was 0.1% (129/106 998). After adjustments for potential confounding factors, the odds ratios (95% confidence intervals) of AF across increasing tertiles of RDW were 1.00 (reference), 1.08 (0.69, 1.67), and 2.65 (1.75, 4.07) (P for trend < .0001), respectively.

CONCLUSIONS

The study demonstrated that elevated RDW is significantly related to higher prevalence of AF in a general Chinese population. Large prospective studies are needed to confirm this finding.

A novel percutaneous stabilizing sheath for minimal invasive epicardial echocardiography and ablation

PURPOSE

Epicardial ablation and mapping are critical adjuncts to the electrophysiologist's approach to arrhythmias; however, ablation within the epicardial space requires the avoidance of coronary arteries (CA). We aimed to evaluate the feasibility and performance of a novel-stabilizing ablation sheath housing an intracardiac echocardiography (ICE) catheter to (1) obtain Epicardial Echocardiography (EE) images, (2) visualize CAs, and (3) enable targeted delivery of radiofrequency energy away from visualized CAs.

METHODS

We designed a sheath that could enclose a regular ICE catheter. This sheath has flanges and a balloon, with three interspersed windows surrounded by an electrode. In an acute canine model (N = 6), the sheath was manipulated within the pericardial space to visualize cardiac structures and CAs. Visualization of CAs was confirmed with angiography. Ablation was then performed through the window either proximal or distal to the CA.

RESULTS

The novel sheath was successfully deployed in six canines, with no acute procedural complications. Images with an excellent spatial resolution of cardiac structures were obtained including the right ventricular outflow tract; aortic, pulmonary, and mitral valves; and left atrial appendage. CAs were successfully visualized, and ablation from a sheath window either proximal or distal to the CA did not produce angiographic or histopathological evidence of CA damage despite evidence of acute injury to the adjacent ablated myocardium.

CONCLUSIONS

This novel percutaneous stabilizing sheath was able to successfully obtain high-quality EE images as well as provide a non-fluoroscopic intra-procedural means to visualize CAs. Use of this sheath enabled successful delivery of energy to avoided CA damage.

The Role of Collaboration Between Electrophysiologists and Surgeons in the Management of Complex Arrhythmia Patients

Although the need for surgery in patients with arrhythmias has declined in the past several decades due to the emergence of catheter ablation, there is still room for collaboration between electrophysiologists and surgeons, mainly when managing patients with atrial fibrillation, ventricular tachycardia, and cardiac implantable electronic devices.

Hybrid atrial fibrillation ablation in patients with persistent atrial fibrillation or failed catheter ablation

Background

Combined ‘hybrid’ thoracoscopic and percutaneous atrial fibrillation (AF) ablation is a strategy used to treat AF in patients with therapy-resistant symptomatic AF. We aimed to study efficacy and safety of single-stage hybrid AF ablation in patients with symptomatic persistent AF, or paroxysmal AF with failed endocardial ablation, and assess determinants of success and quality of life.

Methods

We included consecutive patients undergoing single-stage hybrid AF ablation. First, we performed epicardial ablation, via thoracoscopic access, to isolate the pulmonary veins and superior caval vein and to create a posterior left atrial box. Thereafter, isolation was assessed endocardially and complementary endocardial ablation was performed, followed by cavotricuspid isthmus ablation. Efficacy was assessed by 12-lead electrocardiography and 72-hour Holter monitoring after 3, 6 and 12 months. Recurrence was defined as AF/atrial flutter/tachycardia recorded by electrocardiography or Holter monitoring lasting >30 s during 1‑year follow-up.

Results

Fifty patients were included, 57 ± 9 years, 38 (76%) men, 5 (10%) paroxysmal, 34 (68%) persistent and 11 (22%) long-standing persistent AF. At 1‑year 38 (76%) maintained sinus rhythm off antiarrhythmic drugs. Majority of recurrences were atrial flutter (9/12 patients). Success was associated with type of AF (p = 0.039). Patients with paroxysmal AF had highest success, patients with longstanding persistent AF had lowest success. Seven (14%) patients had procedure-related complications. Quality of life improved after ablation in patients who maintained sinus rhythm.

Conclusion

Success of single-stage hybrid AF ablation was 76% off antiarrhythmic drugs, being associated with type of AF. Quality of life improved significantly, Procedure-related complications occurred in 14%.

Hybrid ablation versus transcatheter ablation for atrial fibrillation: A meta-analysis

BACKGROUND

Despite the successful creation of complex lesion sets during hybrid ablation (HA), reoccurrence of atrial fibrillation (AF), and/or atrial arrhythmia and procedural complications still occur. The main objective of this study was to compare the efficacy and safety between HA and transcatheter ablation (TA).

METHODS

We searched Pubmed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) database up to October 2017. Studies that satisfied our predefined inclusion criteria were included. Of the 894 records, 4 studies encompassing 331 patients were included in our study. We assessed pooled data using random-effect or fixed-effect model. The main endpoint was freedom of atrial arrhythmia after follow-up duration, secondary results were procedure time and intraoperative and postoperative adverse events. Similarly, tertiary outcomes were endocardial time, fluoroscopy time, and postoperative hospitalization.

RESULTS

Compared with TA, HA treatment through mini-thoracotomy access improved superiority in freedom of atrial arrhythmia after follow-up duration (odds ratio [OR] = 6.67, 95% confidence interval [CI]: 2.63-16.90), but HA increased the incidence of intraoperative and postoperative adverse events for AF patients (OR = 2.98, 95% CI: 1.30-6.83). HA through either mini-thoracotomy or transdiaphragmatic/subxiphoid access had longer procedure time and postoperative hospitalization than TA. However, endocardial time was shorter than TA.

CONCLUSIONS

For AF patients, HA possessed of an overall superior outcome using mini-thoracotomy way to TA. Although HA had longer procedure time, it yielded a reduction in endocardial time. Meanwhile, we should pay attention to the significantly high risk of intraoperative and postoperative adverse events that the HA generated.

Staged hybrid procedure versus radiofrequency catheter ablation in the treatment of atrial fibrillation

The treatment effect of the hybrid procedure, consisting of a thoracoscopic ablation followed by an endocardial radiofrequency catheter ablation (RFCA), is unclear. A total of 117 ablation-naïve patients who underwent either the staged hybrid procedure (n = 72) or RFCA alone (n = 105) for drug-refractory, non-valvular persistent or long-standing persistent atrial fibrillation (AF) were enrolled. The primary outcome is occurrence of total atrial arrhythmia, defined as a composite of AF, sustained atrial tachycardia (AT), and atypical atrial flutter (AFL) after index procedure. The mean age was 52.7 years. Eighty-four percentage of the patients were male. Patients with prior history of stroke and long-standing persistent AF were more prevalent in the hybrid group than RFCA group. The left atrial volume index was larger in the hybrid group (P<0.001). During 2.1 years of median follow-up, the incidence of total atrial arrhythmia was not different between the two groups (32.5% vs. 35.7%; adjusted hazard ratio: 0.64; 95% confidence interval: 0.36–1.14; P = 0.13). The AF recurrence was significantly lower in the hybrid group than in the RFCA group (29.6% vs. 34.9%; adjusted HR: 0.53; 95% CI: 0.29–0.99; P = 0.046). The hospital stay was longer in the hybrid group than in the RFCA group (11 days vs. 4 days; P<0.001). A staged hybrid procedure may be an alternative choice for drug-refractory persistent AF, but it is no more effective than RFCA alone to eliminate atrial arrhythmias. Considering the long-length of stay and the morbidity, careful consideration should be given in selection of treatment strategy.

Subxiphoid Hybrid Approach for Epicardial/Endocardial Ablation and LAA Exclusion in Patients with Persistent and Longstanding Atrial Fibrillation

Two patients with long-standing atrial fibrillation (AF) refractory to medical management and with prior pulmonary vein isolation underwent a new hybrid epicardial/endocardial subxyphoid approach for AF ablation and left atrial appendage (LAA) ligation. Pulmonary vein and LA posterior wall isolation, as well as LAA exclusion were achieved in both patients. There were no procedural complications. Both patients remain in sinus rhythm. Both patients are off antiarrhythmic medications.

The safety and efficacy of hybrid ablation for the treatment of atrial fibrillation: A meta-analysis

Introduction

Hybrid ablation, an emerging therapy that combines surgical intervention and catheter ablation, has become a viable option for the treatment of persistent atrial fibrillation. In this analysis, we aimed to evaluate the safety and efficacy of hybrid ablation, as well as compare the outcomes of one-step and staged approaches.

Methods

We conducted a search in major online databases and selected the studies that met the inclusion criteria. The primary endpoint was defined as no episode of atrial fibrillation or atrial tachycardia lasting longer than 30 seconds without administration of antiarrhythmic drugs.

Results

Sixteen studies including 785 patients (paroxysmal atrial fibrillation, n = 83; persistent atrial fibrillation, n = 214; long-standing persistent atrial fibrillation, n = 488) were selected. Average history of atrial fibrillation was (5.0±1.6) years. The pooled proportion of patients who were arrhythmia-free at the primary endpoint was 73% (95% CI, 64%–81%, Cochran’s Q, P<0.001; I² = 81%). The pooled rate of severe short-term complications was 4% (95% CI, 2%–7%, Cochran’s Q, P = 0.01; I² = 51%). The success rate after one-step procedures (69%) was lower than that after staged procedures (78%). The staged approach could ultimately prove to be safer, although complication rates were relatively low for both approaches (2% and 5%, respectively).

Conclusions

Hybrid ablation is an effective and generally safe procedure. The current data suggest that staged hybrid ablation could be the optimal approach, as it is associated with a higher success rate and a seemingly lower complication rate. Additional randomized controlled trials are necessary to confirm these results.

Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times

Atrial fibrillation (AF) and heart failure (HF) are growing cardiovascular disease epidemics worldwide. There has been an exponential increase in the prevalence of AF and HF correlating with an increased burden of cardiac risk factors and improved survival rates in patients with structural heart disease. AF is associated with adverse prognostic outcomes in HF and is most evident in mild-to-moderate left ventricular (LV) dysfunction where the loss of "atrial kick" translates into poorer quality of life and increased mortality. In the absence of underlying structural heart disease, arrhythmia can independently contribute to the development of cardiomyopathy. Together, these 2 conditions carry a high risk of thromboembolism due to stasis, inflammation and cellular dysfunction. Stroke prevention with oral anticoagulation (OAC) remains a mainstay of treatment. Pharmacologic rate and rhythm control remain limited by variable efficacy, intolerance and adverse reactions. Catheter ablation for AF has resulted in a paradigm shift with evidence indicating superiority over medical therapy. While its therapeutic success is high for paroxysmal AF, it remains suboptimal in persistent AF. A better mechanistic understanding of AF as well as innovations in ablation technology may improve patient outcomes in the future. Refractory cases may benefit from atrioventricular junction ablation and biventricular pacing. The value of risk factor modification, especially with regard to obesity, sleep apnea, hypertension and diabetes, cannot be emphasized enough. Close interdisciplinary collaboration between HF specialists and electrophysiologists is an essential component of good long-term outcomes in this challenging population.