Characterizing Recurrence Following Hybrid Ablation in Patients With Persistent Atrial Fibrillation

Abstract

Journal of Patient-Centered Research and Reviews (JPCRR) is an open access, peer-reviewed medical journal focused on disseminating scholarly works devoted to improving patient-centered care practices, health outcomes, and the patient experience. Purpose It is widely accepted that atrial fibrillation (AF) accounts for half of arrhythmia recurrences following endocardial catheter ablation of AF. An epicardial-endocardial approach (hybrid) has emerged as an alternative to endocardial ablation alone for the treatment of AF, yet recurrence after a hybrid procedure has not been well characterized. This retrospective study is aimed at characterizing recurrence following hybrid ablation for patients with persistent AF. Methods Patients with persistent AF (N=108) received both endocardial and epicardial ablation of the posterior left atrial wall using catheter ablation and a small midline surgical approach (hybrid). Presence of atrial flutter or AF was determined with ambulatory monitoring (n=22) or electrocardiogram analysis (n=86) at each follow-up visit. Recurrence mode was confirmed by electrophysiology study for those patients undergoing subsequent catheter ablation after hybrid ablation. Results Patients were followed for a mean ± standard deviation of 25 ± 14 months. Of patients who had a recurrence, 53% (n=33) were in atrial flutter and 47% (n=29) were in AF. Of those who had a recurrence with atrial flutter, 14 received repeat ablation for either left (n=11) or left/right (n=3) atrial flutter and 3 received AF ablation. Half of ablations for atrial flutter recurrence following the hybrid procedure involved the mitral isthmus. Conclusions Atrial flutter accounts for about half of arrhythmia recurrences post-hybrid ablation. If catheter ablation of the mitral isthmus is considered during the hybrid procedure to prevent subsequent occurrence of perimitral flutter, bidirectional block must be performed to ensure a complete line of block.

The hybrid convergent procedure for persistent and long‐standing persistent atrial fibrillation from an electrophysiologist's perspective

“…27,29,31 A single-center study reported their experience of hybrid convergent procedures using a previous generation unipolar RF device and found no statistical differences in recurrence rates of atrial arrhythmias or AF in patients who did and did not have prior ablation. 36 There were significantly higher incidences of need for intraprocedural PVI and intraprocedural direct current cardioversion in patients who did not have prior ablation than those who had prior ablation. Further evaluation in multicenter settings could shed more insight into expected procedural and follow-up outcomes based on previous ablation history.…”

“…Cryoballoon for PVI has been adopted and while it was not permitted in CONVERGE, some investigators have reported on its use in the hybrid convergent procedures. 28,35,36 Several questions also remain regarding the relative effectiveness of the hybrid convergent procedure in subpopulations of patients with advanced AF, such as in those patients with prior ablations compared with those undergoing the procedure de novo.…”

Updates in hybrid AF ablation: a hybrid approach to surgical epicardial ablation and cather endocardial ablation in persistent atrial fibrillation

“…Of patients with recurrence of arrhythmia, 53% were in atrial flutter and 47% were in AF. Half of ablations for atrial flutter following the hybrid procedure ablated the mitral isthmus [36].…”

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

“…A recent single-centre study compared the recurrence of atrial arrhythmias and AF between patients who had a history of prior ablation before hybrid ablation and those who received de novo hybrid ablation and found no significant differences in these outcomes. 72 However, patients who had a history of prior catheter ablation less frequently needed endocardial PVI and cardioversion (to restore sinus rhythm) during the hybrid convergent procedure. Larger, multicentre analyses may be warranted.…”

“…CONVERGE and other published studies used irrigated RF catheters for endocardial ablation, however, some investigators have incorporated the use of endocardial cryoballoon in hybrid convergent procedures. 65,72 Endocardial cryoballoon was reported to be non-inferior to RF ablation for paroxysmal AF treatment, and the STOP PERSISTENT AF trial demonstrated safety and effectiveness of endocardial cryoballoon for the treatment of early (duration less than 6 months) persistent AF. 73,15 Outcomes of hybrid convergent ablation using endocardial cryoballoon have not been formally compared with endocardial RF ablation and may be relevant for future evaluation.…”