JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
METHODS
yielded improved outcomes at one year over either approach alone, success rates, particularly beyond one year, remain disappointingly low for such an invasive procedure. In fact, Pison et al. 10 reported on their experience with such a procedure, with a success rate of 83% at one year follow up without continuous monitoringwith inclusion of PAF patients. Success rates for these procedures may be tempered by edema introduced during the surgical approach which limits electrophysiological mapping either simultaneously or shortly thereafter; thus, resulting in areas of extensive tissueedemamasqueradingas true transmural lesions. In addition, critical areas of arrhythmogenesis may be precluded from appropriate mapping and/or ablation. Krul et al. 13 describe a success rate of 75% at one year (no continuous monitoring was performed) in persistent AF using a real-time mapping approach that required customized equipment or a hybrid EP lab, which are not widely available. We propose that the success rate of a hybrid atrial fibrillation ablation procedure can increase for both persistent AF (PeAF) and long-standing persistent AF (LSPeAF) by having the endocardial approach precede the surgical approach, which most centers should be able to perform. The endo-before –epi surgical hybrid AF ablation procedure is defined by a comprehensive endovascular approach preceding and guiding the epicardial ablation coupled with an extensive epicardial posterior wall ablation to replace the posterior “box lesion” and mitral isthmus lines and their resulting proarrhythmia.
Study Design and Population Thestudywasdesignedasaprospectiveobservational studywith 40 patients being enrolled between January 2012 andDecember 2014. The study was approved by the St. Vincent’s Hospital Institutional Review Board and all patients gave informed consent. All patients had persistent or long-standing persistent AF, were highly symptomatic and had previously failed medical management with a class I or class III antiarrhythmic medication. Patients were chosen for the hybrid procedure if they were considered to be predisposed to a less efficacious outcome from a standard endocardial procedure based on one of the following criteria: (1) persistent AF with failure of antiarrhythmic drug therapy, (2) persistent AF with large left atrial size (> 90mL) by CT scan or concomitant structural heart disease, (3) long-standing persistent AF, and (4) prior failed endocardial ablation. Refer to table 1 for patient characteristics. Patients greater than 18 years of age undergoing the hybrid AF procedure at St. Vincent’s Medical Center Bridgeport, Connecticut were included in this study. Exclusion criteria included: pregnancy, incarceration, severe valvular disease or other cardiac indication for an open procedure and mechanical valves. Procedural complications were predefined as life-threatening or disabling complication or those requiring additional hospitalization for observation (stroke, systemic or pulmonary embolism, esophageal injury other than esophagitis, phrenic nerve injury, symptomatic pulmonary vein stenosis, pericardial effusion with or without tamponnade, groin complications, major bleeding) occurring within 30 days of the procedure. Preoperative Care For patients anticoagulated with warfarin, warfarin was discontinued five days before the endocardial procedure. Epicardial procedures were performed with INR of 1.7 or less. If thepatientwas takinganovel oral anticoagulationagent (NOAC), the NOAC was discontinued 12-48 hours prior and resumed the day after the epicardial procedure. High-risk patients, including those with prior cerebrovascular accident or hypercoagulable states, were bridged with enoxaparin prior to the procedure. If not already prescribed, an antiarrhythmic drug (AAD) was initiated, amiodarone being the drug of choice if tolerated. After oral AAD load, an attempt at restoration of sinus rhythm was performed with one direct current cardioversion. If early recurrence of AF was noted, further attempts at restoration were deferredprior to thehybridAFprocedure. All patients underwent pre-procedural cardiac computer tomography evaluation to delineate the left atrium and pulmonary vein anatomy. Endovascular Approach The procedure is performed over two consecutive days. The endocardial approach was standardized and performed by a single operator. All patients receive a transesophageal echocardiogram to evaluate for intracardiac thrombus as well as other structural abnormalities for repair of which sternotomy would be required, at which time an open surgical Cox Maze procedure could be performed. General anesthesia is used
Baseline Characterisitics
Patient Characteristic Percentage (%) or Mean ± SD Gender Male = 70.0%
61.7 ± 7.9
Age (Years)
BMI (kg/m 2 )
31.3 ± 6.8
AF Type
Persistent = 77.5.0% Long-standing persistent = 22.5%
AF Duration (Years)
6.0 ± 4.5
Mitral Regurgitation
Mild = 52.2% Moderate = 42.5% Severe † =5.0%
LVEF (%)
55.7 ± 5.7
LA Size (cm)
4.7 ± 0.8
LA Volume (cc)
131.5 ± 46.9
Comorbidities
Diabetes = 17.5% Hypertension = 80.0% Obstructive sleep apnea = 55.0%
# of AADs Trialed
1.55 ± 0.7
Prior ablation
Yes = 22.5%
Table 1. Baseline Characterisitics AAD: Antiarrhythmic drug
AF: Atrial fibrillation BMI: Body Mass Index
LVEF: Left ventricular ejection fraction LA: left atrium
†: Refused open proceduret
72 J La State Med Soc VOL 169 MAY/JUNE 2017
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