Abstract 2865: Short Term Results of the Convergent Endo-Epicardial Ablation Procedure for the Treatment of Long Standing Persistent Atrial Fibrillation
Introduction: Long standing persistent atrial fibrillation (LSPAF) is the most challenging form of AF to treat. Percutaneous catheter ablation has shown lower success rate in this subset of AF. Whether a combined epicardial (epi) and endocardial (endo) ablation approach could achieve high cure rate is unknown. The aim of this study was to devise a closed chest procedure which combines endo and epi ablation. An endoscopic trans-diaphragmatic approach with conventional percutaneous endo ablation enables a closed chest procedure that increases the completeness of the lesion pattern.
Methods: 29 patients with LSPAF with left atrium (LA) ≥ than 5 cm have been enrolled in this study. The procedure combined surgical closed chest, epi radiofrequency ablation (nContact, NC, USA) and electrophysiological trans-septal endo ablation (Biosense Webster, NJ, USA). Endoscopically lesions on the posterior LA along the pericardial reflections were created from the coronary sinus (CS) to left pulmonary vein antrum (PV) along the roof to the right PV and bifurcating to the CS and inferior vena cava. Anterior PV lesions were created along the right PV adjacent to the interatrial groove, and the left PV across the ligament of Marshall. Regions of the PV at the pericardial reflections not accessible without chest incisions to dissect, or still connected were ablated endocardially. Entrance and exit block were tested with a circular catheter and segments of persistent conduction were ablated endocardially. Finally, right atrial isthmus and CS lesions were created endocardially. All patients were monitored with repeat Holter and event recorder. In 11 patients an implantable loop recorder was utilized.
Results: All the patients left the operating room in sinus rhythm with confirmed isolation of all PVs. During the perioperative period, 20% needed one, 10% two and 3% three postoperative electrical cardioversions. All the cardioversions were successful in restoring sinus rhythm (SR). At the short term follow up, all patients remained in SR.
Conclusion: The convergent experience combining surgical and electrophysiological expertise appears a good strategy to achieve short term success in patients with LSPAF. Additional data is needed to test the long term efficacy of this approach.