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Mannakkara NN, Porter B, Child N, Sidhu BS, Mehta VS, Elliott MK, Gould J, Ahmed S, Razavi R, Rinaldi CA, Blauth C, Gill JS. Convergent ablation for persistent atrial fibrillation: outcomes from a single-centre real-world experience. Eur J Cardiothorac Surg 2022; 63:6809126. [PMID: 36346176 PMCID: PMC9748999 DOI: 10.1093/ejcts/ezac515] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/09/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES Atrial fibrillation (AF) is common and can cause significant morbidity and detriment to quality of life. Success rates for conventional catheter ablation are suboptimal in persistent AF (PsAF), especially when longstanding. Convergent hybrid ablation combines endoscopic surgical epicardial and endocardial catheter ablation. It offers promise in treating PsAF. We aimed to evaluate outcomes at our centre following convergent ablation. METHODS We conducted an observational study of patients undergoing ablation from 2012 to 2019 at a London cardiac centre. Sixty-seven patients underwent convergent ablation entailing epicardial ablation, mostly via sub-xiphoid access, followed by endocardial left atrial catheter ablation. Baseline and follow-up data were obtained retrospectively from clinical records. Primary outcome was freedom from AF on/off anti-arrhythmic drugs after 12-month follow-up. Secondary outcomes included freedom from AF over the entire follow-up, freedom from anti-arrhythmic drugs, freedom from atrial arrhythmias, symptom status, repeat ablation and complications. RESULTS At baseline, 80.6% had PsAF >1 year (80.6%), 49.3% had body mass index >30 kg/m2 at baseline and 19.4% had left ventricular ejection fraction of 40% or less. The median follow-up was 2.3 (1.4-3.7) years. Freedom from AF recurrence was 81.3% at 1 year and 61.5% over overall follow-up. Eleven patients (16.4%) required redo AF ablation. Prolonged AF duration was associated with increased recurrence at 12 months and duration >5 years with a shorter time to recurrence on Kaplan-Meier analysis, but this and other factors did not significantly impact the AF recurrence during the overall follow-up period. CONCLUSIONS Convergent ablation had good 1-year and overall success rates for treating PsAF. Our results in a diverse, real-world population support the potential of convergent ablation in patients with challenging to treat PsAF.
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Affiliation(s)
- Nilanka N Mannakkara
- Corresponding author. Department of Biomedical Engineering and Imaging Sciences, King’s College London, 4th Floor North Wing, St. Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK. Tel: +44-20-7836-5454; e-mail: (N.N. Mannakkara)
| | - Bradley Porter
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Nicholas Child
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Baldeep S Sidhu
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Vishal S Mehta
- Department of Cardiovascular Services, Guy’s and St. Thomas’ Hospital, London, UK,School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Mark K Elliott
- Department of Cardiovascular Services, Guy’s and St. Thomas’ Hospital, London, UK,School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Justin Gould
- Department of Cardiovascular Services, Guy’s and St. Thomas’ Hospital, London, UK,School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Shahada Ahmed
- Department of Cardiovascular Services, Guy’s and St. Thomas’ Hospital, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Christopher A Rinaldi
- Department of Cardiovascular Services, Guy’s and St. Thomas’ Hospital, London, UK,School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Christopher Blauth
- Department of Cardiovascular Services, Guy’s and St. Thomas’ Hospital, London, UK
| | - Jaswinder S Gill
- Department of Cardiovascular Services, Guy’s and St. Thomas’ Hospital, London, UK,School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
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Kaba RA, Ahmed O, Behr E, Momin A. A Chronicle of Hybrid Atrial Fibrillation Ablation Therapy: From Cox Maze to Convergent. Arrhythm Electrophysiol Rev 2022; 11:e12. [PMID: 35846422 PMCID: PMC9277617 DOI: 10.15420/aer.2022.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/06/2022] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Riyaz A Kaba
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London, UK; Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, Surrey, UK
| | - Omar Ahmed
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Elijah Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Aziz Momin
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London, UK; Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, Surrey, UK
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Shrestha S, Plasseraud KM, Makati K, Sood N, Killu AM, Contractor T, Ahsan S, De Lurgio DB, Shults CC, Eldadah ZA, Russo AM, Knight B, Greenberg YJ, Yang F. Hybrid Convergent Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis. Heart Rhythm O2 2022; 3:396-404. [PMID: 36097459 PMCID: PMC9463711 DOI: 10.1016/j.hroo.2022.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Hybrid Convergent ablation for atrial fibrillation (AF) combines minimally invasive surgical (epicardial) and catheter (endocardial) ablation. The procedural goal is to achieve more extensive, enduring ablation of AF substrate around the pulmonary veins, posterior wall, and vestibule of the posterior wall left atrium. Objective To perform a systematic review and meta-analysis on safety and effectiveness of contemporary Hybrid Convergent procedures. Methods PubMed, Embase, and manual searches identified primary research articles on Hybrid Convergent. Inclusion criteria focused on contemporary practices (epicardial ablation device and lesions). Clinical outcomes at 1 year or later follow-up, patient population, procedural details, and major adverse events (MAE) were recorded. Results Of 249 records, 6 studies (5 observational, 1 randomized controlled trial) including 551 patients were included. Endocardial energy sources included radiofrequency and cryoballoon. Hybrid Convergent ablation was mostly performed in patients with drug-refractory persistent and longstanding persistent AF. Mean preprocedural AF duration ranged between 2 and 5.1 years. Most patients (∼92%) underwent Hybrid Convergent in a single hospitalization. At 1 year follow-up or later, 69% (95% confidence interval [CI]: 61%–78%, n = 523) were free from atrial arrhythmias and 50% (95% CI: 42%–58%, n = 343) were free from atrial arrhythmias off antiarrhythmic drugs. Thirty-day MAE rate was 6% (95% CI: 3%–8%, n = 551). Conclusion Hybrid Convergent ablation is an effective ablation strategy for persistent and longstanding persistent AF. Contemporary procedural approaches and published strategies aim to mitigate complications reported in early experience and address delayed inflammatory effusions.
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Affiliation(s)
| | | | | | - Nitesh Sood
- Southcoast Health System, Fall River, Massachusetts
| | | | | | - Syed Ahsan
- St. Bartholomew’s Hospital, London, United Kingdom
| | | | | | - Zayd A. Eldadah
- Medstar Washington Hospital Center, Washington, District of Columbia
| | - Andrea M. Russo
- Cooper Medical School of Rowan University, Camden, New Jersey
| | | | | | - Felix Yang
- Maimonides Medical Center, Brooklyn, New York
- Address reprint requests and correspondence: Dr Felix Yang, Department of Cardiology, Maimonides Medical Center, 1st Floor Professional Building, 953 49th St, Brooklyn, NY 11219.
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DeLurgio DB. The Hybrid Convergent Procedure for Persistent and Long-Standing Persistent Atrial Fibrillation From an Electrophysiologist's Perspective. J Cardiovasc Electrophysiol 2022; 33:1954-1960. [PMID: 35420730 DOI: 10.1111/jce.15492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/20/2022] [Accepted: 03/10/2022] [Indexed: 12/01/2022]
Abstract
In atrial fibrillation (AF), the pulmonary veins (PV) are central to arrhythmogenicity and are targeted by PV isolation (PVI). As AF progresses, triggers become more prevalent in non-PV areas including the left atrial posterior wall (LAPW). Reported benefits of LAPW isolation in Cox-maze IV led to exploration of ablation strategies using endocardial catheters. However, no single approach to endocardial LAPW isolation exists. Relative success in comparison to PVI alone has been mixed. The hybrid convergent procedure was developed to combine minimally invasive surgical and electrophysiology techniques to accomplish effective PVI and LAPW isolation. Epicardial LAPW isolation is performed by a cardiothoracic surgeon followed by endocardial ablation by an electrophysiologist who ensures PVI completion and targets any remaining gaps. Safety and effectiveness of hybrid convergent was evaluated in the prospective, multi-center, randomized controlled trial, Convergence of Epicardial and Endocardial Ablation for the Treatment of Symptomatic Persistent AF (CONVERGE). CONVERGE compared the effectiveness of the hybrid convergent procedure to endocardial catheter ablation for treatment of drug-refractory persistent and longstanding persistent AF and demonstrated primary effectiveness of higher freedom from atrial arrhythmias absent new/increased dose previously failed/intolerant anti-arrhythmic drugs through 12 months compared to endocardial catheter ablation. Greater freedom from AF and proportion of patients experiencing ≥90% burden reduction with hybrid convergent ablation were seen through 18 months follow-up. Improved electrophysiology lab efficiency was demonstrated by the reduction in endocardial ablation time with addition of epicardial ablation. This multi-disciplinary heart team procedure may improve outcomes in difficult-to-treat patients with advanced AF. This article is protected by copyright. All rights reserved.
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Kaba RA, Momin A, Camm J. Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies. J Clin Med 2021; 10:3129. [PMID: 34300301 PMCID: PMC8304563 DOI: 10.3390/jcm10143129] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/13/2021] [Accepted: 07/13/2021] [Indexed: 01/01/2023] Open
Abstract
Atrial fibrillation (AF) is a global disease with rapidly rising incidence and prevalence. It is associated with a higher risk of stroke, dementia, cognitive decline, sudden and cardiovascular death, heart failure and impairment in quality of life. The disease is a major burden on the healthcare system. Paroxysmal AF is typically managed with medications or endocardial catheter ablation to good effect. However, a large proportion of patients with AF have persistent or long-standing persistent AF, which are more complex forms of the condition and thus more difficult to treat. This is in part due to the progressive electro-anatomical changes that occur with AF persistence and the spread of arrhythmogenic triggers and substrates outside of the pulmonary veins. The posterior wall of the left atrium is a common site for these changes and has become a target of ablation strategies to treat these more resistant forms of AF. In this review, we discuss the role of the posterior left atrial wall in persistent and long-standing persistent AF, the limitations of current endocardial-focused treatment strategies, and future perspectives on hybrid epicardial-endocardial approaches to posterior wall isolation or ablation.
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Affiliation(s)
- Riyaz A. Kaba
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London and St. George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK; (A.M.); (J.C.)
- Ashford and St. Peter’s Hospitals NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Aziz Momin
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London and St. George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK; (A.M.); (J.C.)
- Ashford and St. Peter’s Hospitals NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - John Camm
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London and St. George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK; (A.M.); (J.C.)
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Yi S, Liu X, Wang W, Chen L, Yuan H. Thoracoscopic surgical ablation or catheter ablation for patients with atrial fibrillation? A systematic review and meta-analysis of randomized controlled trials. Interact Cardiovasc Thorac Surg 2020; 31:763-773. [PMID: 33166993 DOI: 10.1093/icvts/ivaa203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/09/2020] [Accepted: 08/17/2020] [Indexed: 12/18/2022] Open
Abstract
Abstract
OBJECTIVES
There is an urgent need to understand the difference in the influence of thoracoscopic surgical ablation (TSA) and catheter ablation (CA) on clinical outcomes in patients with atrial fibrillation (AF). This meta-analysis of randomized controlled trials aimed to examine the efficacy and safety of TSA versus CA in patients with AF.
METHODS
Databases including EMBASE, Clinical Trials, PubMed and Cochrane Central Registered Control System were screened for the retrieval of articles. A direct meta-analysis of TSA versus CA was conducted. The I2 test analysis was performed to evaluate heterogeneity. The Begg–Mazumdar test and the Harbord–Egger test were used to detect publication bias. The primary efficacy outcome was freedom from atrial tachyarrhythmia, while the primary safety outcome was severe adverse event (SAE) occurrence.
RESULTS
Of the 860 identified articles, 6, comprising 466 participants, were finally included. The rate of freedom from AT was higher in the TSA group (75%) than in the CA group (57.1%) (odds ratio 0.41; 95% confidence interval 0.2–0.85; P = 0.02; I2 = 57%). A larger number of SAEs were observed in the TSA group than in the CA group (odds ratio 0.16; 95% confidence interval 0.006–0.46; P = 0.0006; I2 = 44%). The result of the subgroup analysis of 3 studies that enrolled AF patients without a history of ablation showed that the incidence of AT was comparable in both arms. The ablation procedure and hospitalization durations were longer in the TSA arm.
CONCLUSIONS
In our study, TSA was associated with better efficacy but a higher rate of SAEs compared to CA. In addition, TSA did not show better efficacy results as the first invasive procedure in the sub-analysis of patients with paroxysmal AF or early persistent AF. Therefore, doctors should recommend either TSA or CA to patients with AF after due consideration of the aforementioned findings.
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Affiliation(s)
- Shaolei Yi
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Xiaojun Liu
- Department of Cardiology, Zibo Central, Zibo, China
| | - Wei Wang
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Lianghua Chen
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Haitao Yuan
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
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Wats K, Kiser A, Makati K, Sood N, DeLurgio D, Greenberg Y, Yang F. The Convergent Atrial Fibrillation Ablation Procedure: Evolution of a Multidisciplinary Approach to Atrial Fibrillation Management. Arrhythm Electrophysiol Rev 2020; 9:88-96. [PMID: 32983530 PMCID: PMC7491068 DOI: 10.15420/aer.2019.20] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/09/2020] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Karan Wats
- Maimonides Medical Center, Brooklyn, New York, NY, US
| | - Andy Kiser
- St Clair Cardiovascular Surgical Associates, Pittsburgh, PA, US
| | | | | | | | | | - Felix Yang
- Maimonides Medical Center, Brooklyn, New York, NY, US
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Khan Z, Hamandi M, Khan H, DiMaio JM, Evans M. Convergent epicardial-endocardial ablation for treatment of long-standing persistent atrial fibrillation: A review of literature. J Card Surg 2020; 35:1306-1313. [PMID: 32333456 DOI: 10.1111/jocs.14562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/26/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIM OF STUDY The convergent procedure (CVP) is a hybrid ablation technique via a subxiphoid incision that has recently emerged as a treatment option for non-paroxysmal atrial fibrillation (npAF). By combining endocardial and epicardial ablation into a simultaneous or staged procedure, the pulmonary vein and posterior left atrium can be isolated with transmural lesion sets while minimizing the risk of proarrhythmic gaps that are a known limitation with endocardial linear lesion sets. We reviewed the 12-month outcomes in patients who underwent CVP compared to those who underwent endocardial catheter ablation (CA) and surgical ablation (SA). METHODS A literature search was conducted using the PubMed database for publications related to CVP. Selected studies included detailed 12-month follow-up of patients, patient characteristics, periprocedural complications, use of antiarrhythmic drugs (AADs), and monitoring method. RESULTS Five studies with 340 patients who underwent CVP between January 2009 and March 2017 were selected for this review. A total of 8.5% of patients had paroxysmal AF (pAF), 42.2% had persistent AF (peAF), and 49.1% had long-standing persistent AF (lspAF). At 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs. The overall complication rate was 10%. CONCLUSION CVP had better 1-year efficacy in eliminating AF when compared to CA. However, SA, specifically the Cox Maze IV, had lower rates of AF recurrence in the npAF patient population. Despite its promising 1-year efficacy rates, the periprocedural complication rate for CVP was significantly higher than both CA and SA.
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Affiliation(s)
- Zoheb Khan
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Mohanad Hamandi
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Hafiza Khan
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - John Michael DiMaio
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Matthew Evans
- Electrophysiology, Baylor Scott & White The Heart Hospital, Denton, Texas
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