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Maastricht, Netherlands.A small, retrospective study from Netherlands showed favorable outcome with hybrid approach for atrial fibrillation (AF) ablation. The authors report their single institute experience in 26 consecutive patients (42% persistent AF) undergoing a hybrid procedure involving a thoracoscopic surgical and transvenous catheter ablation with 1 year follow-up data. All patients failed at least one antiarrhythmic (AAD) medication and 11 patients had a previous AF or atrial flutter ablation. Mean left atrial dimension (LAD) was 47mm.
Thoracoscopic approach typically included placement of 3 ports on each side of the chest and collapsing both the lungs on general anesthesia. After having access to the epicardial space patients underwent transspetal puncture and circular catheter mapping was performed to identify the ostia of the pulmonary veins (PV). The veins were then isolated as pairs on each side with multiple applications using a bipolar RF clamp (Atricure, West Chester, Ohio). PV isolation was confirmed in all the veins with this approach.
In patients who were still in AF or in whom AF could be induced after PV isolation, a roof line and an inferior line connecting the bilateral veins were performed using a bipolar RF pen or linear pen device (Isolater pen and Coolrail, Atricure). Endocardial and epicardial confirmation of bidirectional block was performed with plans to “touch up” the lesions endocardially, if needed. Additional ablation lines were created if needed including superior vena cava and right atrial junction, mitral isthmus line (both endocardial and epicardial) and cavotricuspid isthmus line (endocardial line). In addition, LA appendage was stapled in 7 patients. Mean procedure time was 280minutes. Importantly, no patients needed open surgery as a complication. One patient had pleural effusion requiring drainage. Mean length of stay in the hospital was 7±2 days.
Patients were followed up as per the standard recommendations including 3, 6, 9 and 12 month visits with 7 day or 24 hours holter monitoring. During follow-up, 4 patients had recurrence after 3 month blanking period of which 2 patients underwent repeat catheter ablation. At 1 year, the single procedure success rate (no AF >30secs after a 3 month blanking period) was 83% (79% for paroxysmal AF and 90% for persistent AF). Overall, 92% of the patients were in sinus rhythm off AADs at the end of 1 year (with 2 patients undergoing repeat procedures).
This is the first report of simultaneous throracoscopic and endoscopic ablation procedure for AF with 1 year follow-up. Though the results are promising, it is clearly very invasive. Patients end up with 2 chest tubes post procedurally with a prolonged length of stay (more than that for a coronary artery bypass surgery). The transmurality of these clamp RF lesions are promising in providing more durable pulmonary vein isolation.
This hybrid approach (either simultaneous or in succession with the endocardial approach a few weeks after the epicardial approach) may play a role in the sickest of the left atria (LAD >5.5cm), where traditional percutaneous catheter ablation has poor long term outcomes. We can just hope that future technical improvements will make the epicardial approach less invasive and easier on the patients while maintaining the good long term outcomes.
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