Transvenous Before Surgical Hybrid Procedure Joseph J. Tiano, MD, Robert Drennan, MD, John Novella, MD, Rafael Squiteri, MD , Malcolm Robinson, MD, Albert DiMeo, MD, Lindsey Scierka, MPH, Paul LeLorier, MD
Background: Historically, persistent atrial fibrillation (PeAF) and long standing persistent atrial fibrillation (LSPeAF) have demonstrated limited clinical success despite hybrid approaches. Objective: We describe our experience with the endocardial-before-epicardial approach defined by a comprehensive endovascular approach preceding and guiding the epicardial approachwhich includes an extensive posterior wall ablation. Methods: 40 patients were followed over a 12 month period. The procedure was performed in a single center. Patients had a mean duration of atrial fibrillation of 6.0 ± 4.5 years with 22.5% having undergone prior ablations. Mean age was 61.7 ± 7.9 years with a mean left atrial volume of 131.5 ± 46.9 mL. The endovascular procedure remained uniform with antral pulmonary vein isolation, posterior left atrial roof and right atrial cavo-tricuspid isthmus (CTI) linear lesions with mapping and ablation of left atrial complex electrograms (CFAEs) and prior existing atrial arrhythmias. The epicardial procedure included a thorascopic approach with ganglionated plexus (GP) mapping and ablation, left atrial posterior wall ablation, directed CFAE ablation and left atrial appendage ligation. All patients received implantable cardiac monitoring. Results: All 40 patients remained in sinus rhythm at their 12 month follow-up. During the monitoring period, episodes of paroxysmal atrial arrhythmias including fibrillation were documented, without persistence, after discontinuation of oral antiarrhythmic medications. Conclusion: The endo-before-epi approach resulted in improved management of persistent and long standing persistent atrial fibrillation over reported results for conventional approaches with no procedural complications, making this a promising option for the management of these arrhythmias.
INTRODUCTION
a much more minimally invasive, video-assisted thoracoscopic approach with bipolar radiofrequency ablation (other energy modalities having come and gone) via clamping and pen with adequate results. 7 However, there still remains difficulty in achieving durable transmural lesions by means of a thoracoscopic approach alone and recurrent atrial arrhythmias can often be seen, up to a 40% rate with one year follow up in an early paper on the subject. 8 Furthermore, confirmation of block andmapping of arrhythmias via an epicardial approach when working alone remains limited and difficult, possibly leading to suboptimal results. 9 This has led to the development of the hybrid AF ablation techniques utilizing both a surgical epicardial approach along with a transvenous endocardial approach, attempting to harness the benefits of each strategy while mitigating their shortcomings and hoping to achieve a synergistic benefit. 10 Currently the two most commonly used minimally invasive approaches in performing the epicardial ablation is either a thoracoscopic approach 10,11 or a pericardioscopic approach. 12 Commonly, the surgical portion of the hybrid approach is prior to the transvenous portion in a staged approach, thereby, in principle, allowing the electrophysiologist to confirm epicardial linear lesions and pulmonary vein isolation (PVI); in addition to decreasing the burden of additional endocardial lesion sets needed to be applied by the electrophysiologist to achieve procedural end-points. While hybrid approaches have
Atrial fibrillation (AF) is the most common chronic arrhythmia requiring treatment in Western society and has become a major health burden. The risk of developing AF from age 40-95 is 26% in men and 23% in women. 1 In the ATRIA study it was estimated that 2.3 million adults in the U.S. had AF in 2006 and 2007 and that this will increase to 5.6-7.6 million by the year 2050. 2,3 Unfortunately, medical management with either rate or rhythm control has yielded suboptimal clinical results leading to further development and advancement of non-pharmacological strategies, including both surgical and endovascular ablations. For patients with documented paroxysmal AF (PAF), catheter- based pulmonary vein isolation has resulted in acceptable results, but long-termsuccess remains disappointing for patients with persistent and long-standing persistent atrial fibrillation. 4 This has led to further refinements in non-pulmonary vein targets including ganglionated plexi, ectopic foci, rotors, and macro re-entrant circuits that enable arrhythmogenic wave fronts. Unfortunately, the addition of lesion sets to address extra-pulmonic substrate does not always lead to higher success rates. 5 Thus, the five year arrhythmia-free survival in non-paroxysmal atrial fibrillation (NPAF) for a single endocardial catheter ablation procedure still remains low and has been reported at 28.4% with the efficacy after multiple procedures at 51.1%. 6 Surgical AF ablation also has evolved from the original open Cox Maze procedure, which never gained widespread acceptance due to its technical complexity and invasiveness, to
J La State Med Soc VOL 169 MARCH/APRIL 2017 71
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