Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation

Abstract

Background - The limited effectiveness of endocardial catheter ablation (CA) for persistent and long-standing persistent atrial fibrillation (Ps/LSP-AF) treatment led to the development of a minimally-invasive epicardial/endocardial ablation approach (Hybrid Convergent) to achieve a more comprehensive lesion set with durable transmural lesions. The multi-center randomized controlled CONVERGE trial (NCT01984346) evaluated the safety of Hybrid Convergent and compared its effectiveness to CA for Ps/LSP-AF treatment. Methods - One-hundred fifty-three patients were randomized 2:1 to Hybrid Convergent vs. CA. Primary effectiveness was freedom from AF/AFL/AT absent new/increased dosage of previously failed/intolerant class I/III anti-arrhythmic drugs (AADs) through 12-months. Primary safety was major adverse events through 30 days. CONVERGE permitted left atrium size up to 6cm and imposed no limits on AF duration, making it the only ablation trial to substantially include LSP-AF i.e. 42% patients with LSP-AF. Results - Of 149 evaluable patients at 12 months, primary effectiveness was achieved in 67.7% (67/99) patients with Hybrid Convergent and 50.0% (25/50) with CA (p=0.036) on/off previously failed AADs and in 53.5% (53/99) versus 32.0% (16/50) (p=0.0128) respectively off AADs. At 18-months using 7-day Holter, 74.0% (53/72) Hybrid Convergent and 55% (23/42) CA patients experienced ≥90% AF burden reduction. A total of 2.9% (3/102) patients had primary safety events within 7 days, and 4.9% (5/102) between 8-30 days post-procedure. No deaths, cardiac perforations or atrioesophageal fistulas occurred. All but one primary safety event resolved. Conclusions - The Hybrid Convergent procedure has superior effectiveness compared to the CA for the treatment of Ps/LSP-AF.

Impact of left atrial posterior wall isolation on arrhythmia outcomes in patients with atrial fibrillation undergoing repeat ablation

“…This is in contrast with the results of the CONVERGE (Convergence Of Epicardial And Endocardial Radiofrequency (RF) Ablation For The Treatment Of Symptomatic Persistent AF) which showed improved arrhythmia free outcomes when a combined endocardial-epicardial approach was used for LAPWI in patients with persistent AF. 22 The epicardial lesion set in this trial included bilateral PV antral encircling lesions and parallel lines connecting LAPW lesions spanning the entire epicardial surface of the LAPW. The endocardial lesion set included routine PV isolation and a roof line only for LAPW isolation without a floor line or additional ablation of fractionated electrograms within the LAPW.…”

Stepwise Endo-/Epicardial Catheter Ablation for Atrial Fibrillation: the Mediterranea Approach

“…9,23 Our stepwise endo-/epicardial approach differs in several ways from previously described hybrid techniques for AF CA. 24,25 Although we gained access to the pericardial space with a small subxiphoid pericardial window, we did not navigate the pericardium under direct vision, and all ablation lesions were delivered by the electrophysiologist using conventional ablation catheters, therefore limiting the need for assistance by the cardiac surgeon to the initial and terminal moments of the procedure. Furthermore, although every case was performed in cooperation with cardiac surgeons, the pericardial access was successfully performed by the electrophysiologist as first operator in the last 15 patients ablated, suggesting that a mini-invasive pericardial access is not surgically demanding.…”

Ablation of persistent atrial fibrillation: the added value of hybrid

“…Not only is there a rising enthusiasm for hybrid approaches in the treatment of persistent atrial fibrillation (AF), but also more and more reports on its efficacy and safety are being published [ 1–3 ]. The concept of attacking the atrial substrate from the epicardium and endocardium seems only logical given the electro-pathological complexity of non-paroxysmal AF and the incomplete understanding of the underlying pathophysiological mechanisms.…”

“…In this and following reports, epicardial ablation was performed with the use of biparietal bipolar radiofrequency (RF) clamps and linear uniparietal bipolar RF devices [ 4–6 ]. Besides this, other epicardial ablation strategies have been incorporated in a one- or two-staged hybrid approach [ 1 , 7 ].…”