Outcomes of convergent atrial fibrillation ablation with continuous rhythm monitoring

Abstract

Background: Outcomes of catheter ablation for persistent atrial fibrillation (PeAF) are suboptimal. The convergent procedure (CP) may offer improved efficacy by combining endocardial and epicardial ablation. Methods:We reviewed 113 consecutive patients undergoing the CP at our institution. The cohort was divided into two groups based on the presence (n = 92) or absence (n = 21) of continuous rhythm monitoring (CM) following the CP. Outcomes were reported in two ways. First, using a conventional definition of any atrial fibrillation/atrial tachycardia (AF/AT) recurrence lasting >30 seconds, after a 90 day blanking period. Second, by determining AF/AT burden at relevant time points in the group with CM.Results: Across the entire cohort, 88% had either persistent or long-standing persistent AF, mean duration of AF diagnosis before the CP was 5.1 ± 4.6 years, 45% had undergone at least one prior AF ablation, 31% had impaired left ventricle ejection fraction and 62% met criteria for moderate or severe left atrial enlargement. Mean duration of follow-up after the CP was 501 ± 355 days. In the entire cohort, survival free from any AF/AT episode >30 seconds at 12 months after the blanking period was 53%. However, among those in the CM group who experienced recurrences, mean burden of AF/AT was generally very low (<5%) and remained stable over the duration of follow-up. Ten patients (9%) required elective cardioversion outside the 90 day blanking period, 11 patients (9.7%) underwent repeat ablation at a mean of 229 ± 178 days post-CP and 64% were off AADs at the last follow-up. Procedural complications decreased significantly following the transition from transdiaphragmatic to sub-xiphoid surgical access: 23% versus 3.8% (P = .005)Conclusions: In a large, consecutive series of patients with predominantly PeAF, the CP was capable of reducing AF burden to very low levels (generally <5%), which appeared durable over time. Complication rates associated with the CP decreased significantly with the transition from transdiaphragmatic to sub-xiphoid surgical

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

“…Further, since there is recovery of electrical conduction following epicardial ablation, it remains important to undertake both components of the hybrid technique to achieve long-lasting, widespread transmurality [ 63 ]. Observational clinical outcomes from contemporary analyses have suggested favourable outcomes with this technique [ 64 , 65 , 66 , 67 , 68 ], which were recently corroborated by the results of the multi-centre, randomised controlled CONVERGE trial [ 69 ]. The trial compared hybrid Convergent ablation with endocardial catheter ablation in PersAF and LSPersAF and met its primary safety and effectiveness endpoints.…”

Robotic-assisted biatrial Cox-maze ablation for atrial fibrillation

“…[3][4][5] Epicardial attempts at minimally invasive ablation, particularly subxiphoid or transdiaphragmatic is often incomplete, does not address the LAA, and may expose to a unique increased set of complications. [6][7][8] Robotic-assisted biatrial surgical ablation can be safely performed as a standalone or concomitant procedure and offers the ability to perform the full Cox-maze III/IV as well as direct LAA obliteration. 9,17 The safety profile and outcomes of robotic surgical ablation may mimic those obtained with sternotomy Cox-maze operations while providing a single-stage, single-incision, minimally invasive procedure to rival alternatives.…”

“…[3][4][5] Furthermore, recent epicardial minimally invasive surgical ablation techniques, particularly subxiphoid, are arrhythmically and antomically incomplete and have potential major safety concerns. [6][7][8] Despite the known effectiveness of the cut-and-sew Coxmaze III, there exists a reluctance on the part of patients, referring cardiologists, and surgeons to carry out a sternotomy for a stand-alone cut-and-sew surgical Cox-maze. Fortunately, the electrophysiologic principles of the Coxmaze III biatrial lesions can be identically and transmurally replicated with alternate power sources consisting of bipolar radiofrequency and/or cryothermia, as the Cox-maze IV procedure (Figure 1).…”

Atrial fibrillation and atrial cardiomyopathies

“…Per the Society of Thoracic Surgeons clinical practice guidelines, surgical ablation for AF is a class I recommendation when performed at the time of concomitant cardiac surgery, such as coronary artery bypass or valve surgery, and several reports document improved survival compared to patients undergoing concomitant surgery without AF treatment 80–85 . Stand‐alone surgical AF ablation continues to have a role in patients who have symptomatic AF that is refractory to AAD and catheter ablation (class IIA, LOE B), especially as a “hybrid” procedure 80,86,87 . Prior data have shown that larger LA size and longer duration of preoperative AF, both of which are linked to more advanced ACM, are predictors of persistent AF after surgical maze procedure 88–90 .…”

“…[80][81][82][83][84][85] Stand-alone surgical AF ablation continues to have a role in patients who have symptomatic AF that is refractory to AAD and catheter ablation (class IIA, LOE B), especially as a "hybrid" procedure. 80,86,87 Prior data have shown that larger LA size and longer duration of preoperative AF, both of which are linked to more advanced ACM, are predictors of persistent AF after surgical maze procedure. [88][89][90] Although surgical ablation has been found to be efficacious in restoring sinus rhythm, the available data to demonstrate a link between LA reverse remodeling parameters and longterm freedom from recurrent AF in those who underwent surgical ablation are overall limited.…”