Convergence of Epicardial and Endocardial RF Ablation for the Treatment of Symptomatic Persistent AF (CONVERGE Trial): Rationale and design

Delurgio, David B.; Ferguson, Edward; Gill, Jaswinder; Blauth, Christopher; Oza, Saumil R.; Mostovych, Mark A.; Awasthi, Yashasvi; Ndikintum, Nfii; Crossen, Karl J.

doi:10.1016/j.ahj.2020.02.016

Cited by 25 publications

(31 citation statements)

References 25 publications

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“… 11 , 12 Interestingly, the recent Converge trial compared endocardial PVI vs. endocardial PVI + posterior wall ablation via a subxiphoid approach and demonstrated improved efficacy in the posterior wall ablated group. 8 This supports the contribution of the posterior wall for AF maintenance and suggest that this should be part of the AF ablation lesion set in patients with persistent AF. Nonetheless, achieving durable box isolation even through a combined epi- and endo-cardial ablation remains a challenge, as shown in our study.…”

Section: Discussionsupporting

confidence: 69%

“…Hybrid AF ablation can be performed either as a single-stage or as a staged procedure, where the endocardial ablation is scheduled at a later stage. In addition, the convergent surgical ablation technique targets mainly the posterior box via a subxiphoid approach, 2 , 8 whereas the bilateral video-assisted thoracoscopic surgery (VATS) allows ablation of the PVs, the posterior box and clipping of the left atrial appendage. As a result, considerable variability exists between hybrid ablation studies.…”

Section: Discussionmentioning

confidence: 99%

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First-line treatment of persistent and long-standing persistent atrial fibrillation with single-stage hybrid ablation: a 2-year follow-up study

et al. 2021

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Aims This study evaluates the efficacy and safety of first-line single-stage hybrid ablation of (long-standing) persistent atrial fibrillation (AF), over a follow-up period of 2 years, and provides additional information on arrhythmia recurrences and electrophysiological findings at repeat ablation. Methods and results This is a prospective cohort study that included 49 patients (65% persistent AF; 35% long-standing persistent AF) who underwent hybrid ablation as first-line ablation treatment (no previous endocardial ablation). Patients were relatively young (57.0 ± 8.5 years) and predominantly male (89.8%). Median CHA2DS2-VASc score was 1.0 (0.5; 2.0) and mean left atrium volume index was 43.7 ± 10.9 mL/m2. Efficacy was assessed by 12-lead electrocardiography and 72-h Holter monitoring after 3, 6, 12, and 24 months. Recurrence was defined as AF/atrial flutter (AFL)/tachycardia (AT) recorded by electrocardiography or Holter monitoring lasting >30 s during 2-year follow-up. At 2-year follow-up, single and multiple procedure success rates were 67% and 82%, respectively. Two (4%) patients experienced a major complication (bleeding) requiring intervention following hybrid ablation. Among the 16 (33%) patients who experienced an AF/AFL/AT recurrence, 13 (81%) were ATs/AFLs and only 3 (19%) were AF. Repeat ablation was performed in 10 (20%) patients and resulted in sinus rhythm in 7 (70%) at 2-year follow-up. Conclusion First-line single-stage hybrid AF ablation is an effective treatment strategy for patients with persistent and long-standing persistent AF with an acceptable rate of major complications. Recurrences are predominantly AFL/AT that can be successfully ablated percutaneously. Hybrid ablation seems a feasible approach for first-line ablation of (long-standing) persistent AF.

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Section: Discussionsupporting

confidence: 69%

Section: Discussionmentioning

confidence: 99%

First-line treatment of persistent and long-standing persistent atrial fibrillation with single-stage hybrid ablation: a 2-year follow-up study

et al. 2021

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“…The prospective, multicenter, randomized controlled clinical trial CONVERGE (ClinicalTrials.gov identifier NCT019 84346) demonstrated superiority of the hybrid Convergent approach vs an endocardial-only approach in treating nonparoxysmal AF. 14 The hybrid approach achieved 1-year freedom of atrial arrhythmias absent new/increased dose of previously failed class I/III antiarrhythmic drugs in 67.7% vs 50.0% using conventional techniques (P 5 .036). Further questions remain given the heterogeneity of endocardial approaches and adoption of additional epicardial procedures.…”

Section: J Future Directionsmentioning

confidence: 95%

“…Feedback from the electrophysiologist on the LAPW lesion set may be particularly helpful during the surgical learning phase. Hybrid Convergent ablation was applied as a de novo procedure in the CONVERGE clinical trial 14 and for patients with enlarged atria (.4-5 cm), high body mass index, and longer duration of long-standing persistent AF. Given that catheter ablation improves outcomes in patients with heart failure and persistent AF, 15 patients with heart failure and reduced ejection fraction could potentially be considered; some reports have included low ejection fraction subgroups.…”

Section: C2 Single Length Of Stay Vs Dual Length Of Stay (Or Staged) Programsmentioning

confidence: 99%

Combined epicardial and endocardial ablation for atrial fibrillation: Best practices and guide to hybrid convergent procedures

et al. 2021

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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 Funding sources: The authors have no funding sources to disclose. Disclosures: Dr Makati serves as a consultant, advisor, and proctor for AtriCure, Boston Scientific, and Medtronic and has received research grants from AtriCure, Boston Scientific, and Medtronic. He serves on speakers bureau for Abbott. Dr Sood serves as a consultant for AtriCure. Dr Lee serves as a consultant for AtriCure. Dr Yang serves as a consultant for AtriCure. Dr Shults serves as a consultant for AtriCure and Medtronic and as a proctor for AtriCure. Dr DeLurgio serves as a consultant for AtriCure, Boston Scientific, and Medtronic and on speakers bureau for AtriCure and Boston Scientific. Dr Gill has received research funding from Abbott and lecture honoraria from AtriCure. Dr Kaba serves as a consultant for AtriCure and Biotronik and on speakers bureau for Daiichi Sankyo and Bayer. Dr Ahsan serves on speakers bureau for AtriCure, Biosense Webster, and Boston Scientific. Dr Lellouche serves as a consultant for Medtronic, Abbott, Boston Scientific, and AtriCure. Dr Blaauw has received department research funding from AtriCure and Medtronic and serves as a proctor for AtriCure, Medtronic, Boston Scientific, and Abbott. Dr Zannis serves as a proctor for AtriCure. Dr Sebag serves as a consultant for AtriCure. Dr Gauri serves as a consultant for Medtronic, IRhythm, and AtriCure. Dr Zembala serves as a proctor for AtriCure and as a consultant for Balton, Abbott, and Boston Scientific.

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“…Hybrid ablation strategies may improve outcome over single-staged surgical-only strategies, however, large randomised studies including patients with HF are definitely waited for. [45][46][47] Clearly, future research endeavours should be performed into the field of high-power short duration, pulsed field ablation and hybrid/convergent AF ablation strategies in patients with AF and HF.…”

Section: Which Ablation Strategy To Be Used In Patients With Hfmentioning

confidence: 99%

Update on management of atrial fibrillation in heart failure: a focus on ablation

Mulder

Rienstra

Gelder

et al. 2021

Heart

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Atrial fibrillation is increasingly encountered in patients with heart failure. Both diseases have seen tremendous rises in incidence in recent years. In general, the treatment of atrial fibrillation is focused on relieving patients from atrial fibrillation-related symptoms and risk reduction for thromboembolism and the occurrence or worsening of heart failure. Symptomatic relief may be accomplished by either (non-)pharmacological rate or rhythm control in combination with optimal therapy of underlying cardiovascular morbidities and risk factors. Atrial fibrillation ablation has been performed in patients without overt heart failure successfully for many years. However, in recent years, attempts have been made for patients with heart failure as well. In this review, we discuss the current literature describing the treatment of atrial fibrillation in heart failure. We highlight the early rate versus rhythm control studies, the importance of addressing underlying conditions and treatment of risk factors. A critical evaluation will be performed of the catheter ablation studies that have been performed so far in light of larger (post-hoc) ablation studies. Furthermore, we will hypothesise the role of patient selection as next step in optimising outcome for patient with atrial fibrillation and heart failure.

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Convergence of Epicardial and Endocardial RF Ablation for the Treatment of Symptomatic Persistent AF (CONVERGE Trial): Rationale and design

Cited by 25 publications

References 25 publications

First-line treatment of persistent and long-standing persistent atrial fibrillation with single-stage hybrid ablation: a 2-year follow-up study

First-line treatment of persistent and long-standing persistent atrial fibrillation with single-stage hybrid ablation: a 2-year follow-up study

Combined epicardial and endocardial ablation for atrial fibrillation: Best practices and guide to hybrid convergent procedures

Update on management of atrial fibrillation in heart failure: a focus on ablation

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