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Lorenzo C, Ortiz-Gonzalez Y, Hill D, Kinaga J, Filart L, Bello D, Duran A, Bott J, Patel S, Sendin MJ, Filart R. Real-world evidence demonstrates an appropriate atrial fibrillation population for hybrid convergent approach versus stand-alone cryoballoon ablation: A long-term safety and efficacy study. J Cardiovasc Electrophysiol 2024; 35:1624-1632. [PMID: 38898656 DOI: 10.1111/jce.16327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 05/05/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION A hybrid convergent approach (endocardial and epicardial ablation) demonstrated superior effectiveness in a recent randomized study for long-standing persistent atrial fibrillation (LSPAF). Yet, there is a lack of real-world, long-term evidence as to which patients are best candidates for a hybrid convergent approach compared to standard endocardial cryoballoon pulmonary vein isolation (CB PVI). METHODS AND RESULTS This single-center, retrospective analysis spanning from 2010 to 2015 compared two distinctly different atrial fibrillation (AF) cohorts; one treated with stand-alone cryoablation and one treated with a hybrid convergent approach. Baseline characteristics described candidates for each approach. The following criteria were utilized to determine CB PVI candidacy: (1) paroxysmal AF (PAF) (stage 3A) with failed class I/III antiarrhythmic drug (AAD) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD unwilling to undergo hybrid procedure. Selection criteria for the hybrid procedure included: (1) PAF refractory to both class I/III AAD and prior CB PVI (stage 3D) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD agreeable to hybrid procedure. Prior sternotomy was excluded. Serial electrocardiograms and continuous monitoring evaluated primary efficacy outcome of time-to-first recurrence of atrial arrhythmia after a 90-day blanking period. Secondary outcomes were procedure-related complications and AAD use (at discharge, 12, and 36 months). Kaplan-Meier methods evaluated arrhythmia recurrence. Of 276 patients, 197 (64.2 ± 10.6 years old; 66.5% male; 74.1% 3A-PAF; 18.3% 3B/3D-persistent AF; 1.0% 3C-LSPAF; 6.6% undetermined) underwent CB PVI and 79 (61.4 ± 8.1 years old; 83.5% male; 41.8% 3D-PAF; 45.5% 3B/3D-persistent AF; 12.7% 3C/3D-LSPAF) underwent hybrid procedure. Arrhythmia freedom through 36 months was 55.2% for CB PVI and 50.4% for hybrid (p = .32). Class I AAD utilization at discharge occurred in 38 (19.3%) patients in the CB PVI group and 5 (6.3%) patients in the hybrid group (p = .01). CB PVI class I AAD utilization at 12 months occurred in 14 (9.0) patients versus 0 patients for hybrid convergent (p = .004). Patients with one or more adverse event were as follows: two (1.0%) in the CB PVI group (both transient phrenic nerve palsy) and three (3.7%) in the hybrid group (two with significant bleeding and one with wound infection) (p = .14). CONCLUSION This study demonstrated that patients with more complex forms of AF (3D-PAF or 3B/3C/3D-persistent/LSPAF) could be well managed with a convergent approach. In a real-world evaluation, outcomes match safety and efficacy thresholds achieved for patients with earlier, less complex AF etiologies treated by CB PVI alone.
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Affiliation(s)
- Christian Lorenzo
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Yahaira Ortiz-Gonzalez
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Dustin Hill
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Jennifer Kinaga
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Lauren Filart
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - David Bello
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Aurelio Duran
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Jeffery Bott
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Shivangi Patel
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Mary Janette Sendin
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Roland Filart
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
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Sha R, Baines O, Hayes A, Tompkins K, Kalla M, Holmes AP, O'Shea C, Pavlovic D. Impact of Obesity on Atrial Fibrillation Pathogenesis and Treatment Options. J Am Heart Assoc 2024; 13:e032277. [PMID: 38156451 PMCID: PMC10863823 DOI: 10.1161/jaha.123.032277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia. AF increases the risk of stroke, heart failure, dementia, and hospitalization. Obesity significantly increases AF risk, both directly and indirectly, through related conditions, like hypertension, diabetes, and heart failure. Obesity-driven structural and electrical remodeling contribute to AF via several reported mechanisms, including adiposity, inflammation, fibrosis, oxidative stress, ion channel alterations, and autonomic dysfunction. In particular, expanding epicardial adipose tissue during obesity has been suggested as a key driver of AF via paracrine signaling and direct infiltration. Weight loss has been shown to reverse these changes and reduce AF risk and recurrence after ablation. However, studies on how obesity affects pharmacologic or interventional AF treatments are limited. In this review, we discuss mechanisms by which obesity mediates AF and treatment outcomes, aiming to provide insight into obesity-drug interactions and guide personalized treatment for this patient subgroup.
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Affiliation(s)
- Rina Sha
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Olivia Baines
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Abbie Hayes
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Katie Tompkins
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Manish Kalla
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Andrew P. Holmes
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Christopher O'Shea
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Davor Pavlovic
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
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3
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De Lurgio DB. Selection of patients for hybrid ablation procedure. J Cardiovasc Electrophysiol 2023; 34:2179-2187. [PMID: 37003267 DOI: 10.1111/jce.15901] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/07/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
Catheter ablation for treatment of symptomatic non-paroxysmal atrial fibrillation remains challenging. Clinical failure and need for continued medical therapy or repeat ablation is common, especially in more advanced forms of atrial fibrillation. Hybrid ablation has emerged as a more effective and safe therapy than endocardial-only ablation particularly for longstanding persistent atrial fibrillation as demonstrated by the randomized controlled CONVERGE trial. Hybrid ablation requires collaboration of electrophysiologists and cardiac surgeons to develop specific workflows. This review describes the Hybrid Convergent approach in the context of available ablation options and offers guidance for workflow development and patient selection.
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Affiliation(s)
- David B De Lurgio
- Emory St. Joseph's Hospital Suite 300, Emory University, Atlanta, Georgia, USA
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4
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Eranki A, Wilson-Smith A, Flynn C, Williams M, Manganas C. Mid term freedom from atrial fibrillation following hybrid ablation, a systematic review and meta analysis. J Cardiothorac Surg 2023; 18:155. [PMID: 37076929 PMCID: PMC10114378 DOI: 10.1186/s13019-023-02189-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/21/2023] [Indexed: 04/21/2023] Open
Abstract
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.
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Affiliation(s)
- Aditya Eranki
- Department of Cardiothoracic Surgery, St. George Hospital, Kograh, Sydney, 2217, Australia.
| | - Ashley Wilson-Smith
- The Chris O'Brien Lifehouse Center, Sydney, Australia
- The Collaborative Research Group (CORE), Sydney, Australia
- The University of Sydney, Sydney, Australia
- The John Hunter Hospital, Newcastle, Australia
| | - Campbell Flynn
- Department of Cardiothoracic Surgery, St. George Hospital, Kograh, Sydney, 2217, Australia
| | - Michael Williams
- Department of Cardiothoracic Surgery, Dunedin Hospital, Great King Street, Dunedin Otago, New Zealand
| | - Con Manganas
- Department of Cardiothoracic Surgery, St. George Hospital, Kograh, Sydney, 2217, Australia
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5
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DeLurgio DB, Blauth C, Halkos ME, Crossen KJ, Talton D, Oza SR, Magnano AR, Mostovych MA, Billakanty S, Duff S, Stees C, Sperling J, Ahsan S, Yap J, Shults C, Pederson D, Garrison J, Tabereaux P, Gilligan DM, Bundy G, Costantini O, Espinal E, La Pietra A, Yang F, Greenberg Y, Jacobowitz I, Gill J. Hybrid epicardial-endocardial ablation for long-standing persistent atrial fibrillation: A subanalysis of the CONVERGE Trial. Heart Rhythm O2 2023; 4:111-118. [PMID: 36873309 PMCID: PMC9975017 DOI: 10.1016/j.hroo.2022.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Karl J Crossen
- Cardiology Associates Research, LLC, Tupelo, Mississippi
| | - David Talton
- Cardiology Associates Research, LLC, Tupelo, Mississippi
| | | | | | | | | | - Steven Duff
- Riverside Methodist Hospital, OhioHealth, Columbus, Ohio
| | | | - Jason Sperling
- HealthOne Cardiothoracic Surgery Associates, Aurora, Colorado
| | - Syed Ahsan
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - John Yap
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | - David Pederson
- STAR Clinical Trials/Methodist Cardiology Clinic San Antonio, San Antonio, Texas
| | - James Garrison
- STAR Clinical Trials/Methodist Cardiology Clinic San Antonio, San Antonio, Texas
| | | | | | - Graham Bundy
- Virginia Cardiovascular Specialists, Richmond, Virginia
| | | | | | | | - Felix Yang
- Maimonides Medical Center, Brooklyn, New York
| | | | | | - Jaswinder Gill
- Guy's and St. Thomas' Foundation Trust, London, United Kingdom
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6
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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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7
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Ranjan R, Kaba R, Chandrasekaran V, Momin A. The Convergent Ablation and AtriClip Exclusion of the Left Atrial Appendage in Long-Standing Persistent Atrial Fibrillation. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2022; 15:11795476221120778. [PMID: 36046371 PMCID: PMC9421220 DOI: 10.1177/11795476221120778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Redoy Ranjan
- Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.,St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Riyaz Kaba
- St. George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Aziz Momin
- St. George's University Hospitals NHS Foundation Trust, London, UK
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8
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Eranki A, Wilson-Smith AR, Williams ML, Flynn CD, Manganas C. Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: a systematic review and meta-analysis of randomised control trials and propensity matched studies. J Cardiothorac Surg 2022; 17:181. [PMID: 35964093 PMCID: PMC9375401 DOI: 10.1186/s13019-022-01930-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
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. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01930-7.
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Affiliation(s)
- Aditya Eranki
- Department of Cardiothoracic Surgery, St George Hospital, Gray Street Kogarah, Sydney, Australia.
| | - Ashley R Wilson-Smith
- Department of Cardiothoracic Surgery, John Hunter Hospital, Lookout Road, Newcastle, Australia.,The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Michael L Williams
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Department of Cardiothoracic Surgery, Dunedin Hospital, Great King Street, Dunedin, Otago, New Zealand
| | - Campbell D Flynn
- Department of Cardiothoracic Surgery, St George Hospital, Gray Street Kogarah, Sydney, Australia.,The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Con Manganas
- Department of Cardiothoracic Surgery, St George Hospital, Gray Street Kogarah, Sydney, Australia
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9
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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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10
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Hao J, Xi Y, Chen W, Liang Y, Lin Z, Wei W. Hybrid ablation procedure for the treatment of nonparoxysmal atrial fibrillation: A systematic review and meta-analysis. Pacing Clin Electrophysiol 2022; 45:1132-1140. [PMID: 35616829 DOI: 10.1111/pace.14539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/13/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Junhai Hao
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yue Xi
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Wanwen Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuanfeng Liang
- Institute of Geriatric medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Zhanyi Lin
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Institute of Geriatric medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Wei Wei
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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11
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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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12
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Sheth AR, Al Yafeai Z, Dominic P. Adverse events related to AtriCure EPi-Sense Coagulation Device-Analysis of the FDA MAUDE database. J Cardiovasc Electrophysiol 2022; 33:151-153. [PMID: 34750929 PMCID: PMC8813877 DOI: 10.1111/jce.15287] [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: 08/09/2021] [Revised: 10/05/2021] [Accepted: 10/20/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The AtriCure EPi-Sense Device is used for the hybrid convergent procedure, an emerging treatment for persistent atrial fibrillation (AF) and long-standing persistent AF. However, data on the AE related to the EPi-Sense device are scarce. METHODS Keyword "EPI-SENSE" was searched on the MAUDE database. There were 80 device reports from 2016 to 2020. After excluding reports when the device was not returned for evaluation, 79 device reports were included for final analysis. RESULTS The adverse events (AE) were broadly classified into 11 categories. The most common complications were pericardial effusion (25.3%), stroke (17.7%), and atrioesophageal fistula (AEF) (8.9%). Death was reported in 15 (19%) cases, 3 of which were due to pulmonary embolism, 6 due to AEF, 3 due to unknown cause, 1 due to sepsis, 2 due to events related to acute renal failure. DISCUSSION Pericardial effusion is a common AE reported in patients with convergence procedures and is well documented in the CONVERGE trial. The convergent procedure is unique in that the epicardial ablations are performed on the posterior wall with the radiofrequency probe directed towards the heart and away from the esophagus which in theory should reduce esophageal injuries. Despite that, a high number of AEF were noticed. Finally, there were also some reports of saline perfusion malfunction which can lead to injuries due to overheating. CONCLUSION This analysis of the AE related to the EPi-Sense device highlights several major AE that are previously unreported.
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Affiliation(s)
- Aakash R Sheth
- The Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center-Shreveport, Louisiana
| | - Zaki Al Yafeai
- The Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center-Shreveport, Louisiana
| | - Paari Dominic
- The Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center-Shreveport, Louisiana
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Kubota H, Ohtsuka T, Ninomiya M, Nonaka T, Hisagi M, Endo H, Minegishi S, Tsuchiya H, Inaba Y. Thoracoscopic infrared ablation to create a box lesion as a treatment for atrial fibrillation. J Cardiothorac Surg 2022; 17:1. [PMID: 34996500 PMCID: PMC8742376 DOI: 10.1186/s13019-021-01750-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 12/29/2021] [Indexed: 11/24/2022] Open
Abstract
Background Creating a box lesion in the posterior wall of the left atrium from the epicardial side of the beating heart remains a challenge. Although a transmural lesion can be created by applying radiofrequency (RF) energy at clampable sites, it is still difficult to create a transmural lesion at unclampable sites because the inner blood flow in the unclampable free wall weakens the thermal effect on the outside. Our aim was to apply the newly developed infrared coagulator to create linear transmural lesions on the beating heart thoracoscopically to treat atrial fibrillation (AF). Case presentation A 71-year-old male was referred to our hospital with a diagnosis of hypertrophic cardiomyopathy and permanent atrial fibrillation. The patient was first diagnosed with atrial fibrillation 20 years before. Direct current cardioversion had been performed every few years a total of four times, but sinus rhythm restoration had always been temporary. On February 27, 2020, thoracoscopic PV isolation together with infrared roof- and bottom-line ablation to create a box lesion and left atrial appendage amputation (LAAA) were performed. The coagulator could be applied to clinical thoracoscopic surgery to successfully create a box lesion without any complication. The patient restored a regular sinus rhythm, it has been maintained for eleven months, and there have been no adverse events. Conclusions The infrared coagulator might have enough potential to create transmural lesions on the beating heart in thoracoscopic AF surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01750-1.
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Affiliation(s)
- Hiroshi Kubota
- Department of Cardiovascular Surgery, Kyorin University, 6-20-2, Shinkawa,Tokyo, Mitaka, 181-8611, Japan.
| | - Toshiya Ohtsuka
- Department of Cardiac Surgery, New Heart Watanabe Institute, Tokyo, Japan
| | - Mikio Ninomiya
- Department of Cardiovascular Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Takahiro Nonaka
- Department of Cardiovascular Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Motoyuki Hisagi
- Department of Cardiovascular Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Hidehito Endo
- Department of Cardiovascular Surgery, Kyorin University, 6-20-2, Shinkawa,Tokyo, Mitaka, 181-8611, Japan
| | - Sachito Minegishi
- Department of Cardiovascular Surgery, Kyorin University, 6-20-2, Shinkawa,Tokyo, Mitaka, 181-8611, Japan
| | - Hiroshi Tsuchiya
- Department of Cardiovascular Surgery, Kyorin University, 6-20-2, Shinkawa,Tokyo, Mitaka, 181-8611, Japan
| | - Yusuke Inaba
- Department of Cardiovascular Surgery, Kyorin University, 6-20-2, Shinkawa,Tokyo, Mitaka, 181-8611, Japan
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Brancato SC, Wang M, Spinelli KJ, Gandhavadi M, Worrall NK, Lehr EJ, DeBoard ZM, Fitton TP, Leiataua A, Piccini JP, Gluckman TJ. Temporal trends and predictors of surgical ablation for atrial fibrillation across a multistate healthcare system. Heart Rhythm O2 2021; 3:32-39. [PMID: 35243433 PMCID: PMC8859806 DOI: 10.1016/j.hroo.2021.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Multiple class I and class IIa recommendations exist related to surgical ablation (SA) of atrial fibrillation (AF) in patients undergoing cardiac surgery. Objective Examine temporal trends and predictors of SA for AF in a large US healthcare system. Methods We retrospectively analyzed data from the Society for Thoracic Surgery (STS) Adult Cardiac Surgery Database for 21 hospitals in the Providence St. Joseph Health system. All patients with preoperative AF who underwent isolated coronary artery bypass graft (CABG) surgery, isolated aortic valve replacement (AVR), AVR with CABG surgery (AVR+CABG), isolated mitral valve repair or replacement (MVRr), and MVRr with CABG surgery (MVRr+CABG) from July 1, 2014, to March 31, 2020 were included. Temporal trends in SA were evaluated using the Cochran-Armitage trends test. A multilevel logistic regression model was used to examine patient-, hospital-, and surgeon-level predictors of SA. Results Among 3124 patients with preoperative AF, 910 (29.1%) underwent SA. This was performed most often in those undergoing isolated MVRr (n = 324, 44.8%) or MVRr+CABG (n = 75, 35.2%). Rates of SA increased over time and were highly variable between hospitals. Years since graduation from medical school for the primary operator was one of the few predictors of SA: odds ratio (95% confidence interval) = 0.71 (0.56–0.90) for every 10-year increase. Annual surgical (both hospital and operator) and AF catheter ablation volumes were not predictive of SA. Conclusion Wide variability in rates of SA for AF exist, underscoring the need for greater preoperative collaboration between cardiologists, electrophysiologists, and cardiac surgeons.
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Mhanna M, Beran A, Al‐Abdouh A, Ayesh H, Sajdeya O, Srour O, Alsaiqali M, Alhasanat OH, Burmeister C, Abumoawad AM, Chacko P. Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: A systematic review and meta-analysis. J Arrhythm 2021; 37:1459-1467. [PMID: 34887950 PMCID: PMC8637076 DOI: 10.1002/joa3.12653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/09/2021] [Accepted: 10/21/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mohammed Mhanna
- Department of Internal MedicineUniversity of ToledoToledoOHUSA
| | - Azizullah Beran
- Department of Internal MedicineUniversity of ToledoToledoOHUSA
| | - Ahmad Al‐Abdouh
- Department of Internal MedicineSaint Agnes HospitalBaltimoreMDUSA
| | - Hazem Ayesh
- Department of Internal MedicineUniversity of ToledoToledoOHUSA
| | - Omar Sajdeya
- Department of Internal MedicineUniversity of ToledoToledoOHUSA
| | - Omar Srour
- Department of Internal MedicineUniversity of ToledoToledoOHUSA
| | - Mahmoud Alsaiqali
- Department of Internal MedicineState University of New York Downstate Medical CenterBrooklynNYUSA
| | | | | | | | - Paul Chacko
- Department of Cardiovascular MedicineUniversity of ToledoToledoOHUSA
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DeLurgio DB, Gill JS, Ahsan S, Kaba RA, Plasseraud KM, Halkos ME. Hybrid Convergent Procedure for the Treatment of Persistent and Long-standing Persistent Atrial Fibrillation. Arrhythm Electrophysiol Rev 2021; 10:198-204. [PMID: 34777825 PMCID: PMC8576514 DOI: 10.15420/aer.2021.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/08/2021] [Indexed: 01/01/2023] Open
Abstract
Recent advances have been made in AF treatment, including the role of early rhythm control and landmark clinical trials using ablation therapy. However, some treatment gaps remain, including the creation of durable lesions outside the pulmonary veins and effective treatment of longstanding persistent AF. A novel epicardial-endocardial ablation approach - the hybrid convergent procedure - was developed to combine surgical and catheter ablation techniques into a collaborative, multidisciplinary approach to managing AF. In this review, the authors discuss recently published data on hybrid convergent ablation, including results of the CONVERGE clinical trial, in the context of current challenges to treatment of persistent and long-standing persistent AF. The review also aims to provide perspective on outstanding questions and future directions in this area.
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Affiliation(s)
| | | | | | - Riyaz A Kaba
- St George’s University Hospitals NHS Foundation Trust, London, UK
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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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Rhythm Control of Persistent Atrial Fibrillation in Systolic Heart Failure: A Bayesian Network Meta-Analysis of Randomized Controlled Trials. INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:179-193. [PMID: 36262637 PMCID: PMC9536657 DOI: 10.36628/ijhf.2021.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/02/2021] [Accepted: 06/09/2021] [Indexed: 12/28/2022]
Abstract
Background and Objectives Methods Results Conclusions
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Combined epicardial and endocardial ablation for atrial fibrillation: Best practices and guide to hybrid convergent procedures. Heart Rhythm 2020; 18:303-312. [PMID: 33045430 DOI: 10.1016/j.hrthm.2020.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/24/2020] [Accepted: 10/04/2020] [Indexed: 02/07/2023]
Abstract
The absence of strategies to consistently and effectively address nonparoxysmal atrial fibrillation by nonpharmacological interventions has represented a long-standing treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to complete isolation of the pulmonary veins and for additional ablation as needed. Experience gained with the hybrid Convergent procedure during the last decade has led to the development and adoption of strategies to optimize the technique and mitigate risks. Additionally, a surgical and electrophysiology "team" approach including comprehensive training is believed critical to successfully develop the hybrid Convergent program. A recently completed randomized clinical trial indicated that this ablation strategy is superior to an endocardial-only approach for patients with persistent atrial fibrillation. In this review, we propose and describe best practice guidelines for hybrid Convergent ablation on the basis of a combination of published data, author consensus, and expert opinion. A summary of clinical outcomes, emerging evidence, and future perspectives is also given.
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