A heart-team hybrid approach for atrial fibrillation: a single-centre long-term clinical outcome cohort study

Abstract

OBJECTIVES The Cox-maze IV is the gold standard for surgical ablation of atrial fibrillation (AF). A heart-team hybrid approach using selected epicardial thoracoscopic surgical ablations and completion endocardial ablations to replicate the Cox-maze IV lesion set has gained popularity and early results have been promising. We herein report our single-centre long-term clinical outcomes using the heart-team hybrid approach with 455 patients. METHODS From 1 March 2013 to 1 July 2019, we prospectively collected data on all patients referred to our heart team for rhythm-control strategy for AF. Baseline characteristics, procedural complications and long-term freedom from AF (FFAF) both on and off anti-arrhythmic drug therapy were analysed. Ambulatory monitoring (>7 days) was obtained at 3 months and annually thereafter. RESULTS Four hundred and fifty-five patients completed the hybrid approach. Four hundred and forty-five (97.8%) patients had non-paroxysmal AF (long-standing persistent AF n = 249, 54.7%; persistent AF n = 196, 43.1%; paroxysmal AF n = 10, 2.2%). Average duration of AF was 5.9 ± 6.1 years. Average left atrial diameter was 4.8 ± 0.8 cm. FFAF at 3, 12, 24 and 36 months was 92%, 87%, 81% and 72%, respectively. FFAF without the use of anti-arrhythmic medications was 75%, 81%, 76% and 66%. Any surgical complications occurred in 28 (6.1%) patients. CONCLUSIONS A heart-team hybrid strategy for the treatment of AF is safe and effective. In a predominantly non-paroxysmal population with AF, at the 3-year follow-up, FFAF in patients on and off anti-arrhythmic drugs approaches that of patients who had the Cox-maze IV.

Left Atrial Appendage Ligation Using the AtriClip Device: Single-Center Study of Device Safety and Efficacy

“…Eur J Cardiothorac Surg 2021;60(6):1343–1350, by permission of the European Association for Cardio-Thoracic Surgery. 8 (b) AtriClip 35 mm deployed. (c) Two-dimensional TEE imaging revealing complete exclusion of the left atrial appendage orifice.…”

Staged hybrid totally thoracoscopic maze and catheter ablation for atrial fibrillation

“…Half of the patients were persistent and long‐standing persistent AF. The group from California recently published their results analyzing over 450 patients 15 . Almost all of the patients had nonparoxysmal AF.…”

“…The group from California recently published their results analyzing over 450 patients. 15 Almost all of the patients had nonparoxysmal AF. At 3 years, freedom from AF was 72%.…”

“…Hybrid ablations include the Convergent procedure 3,14 and full plethora of other thoracoscopic approaches. Some of the surgical procedures mirror the full Cox-Maze III or IV approach 15,16 while others lack the complete set of Maze lesions.…”

The Convergent procedure for AF: A surgeon's perspective

“…This requires surgical encircling of the left pulmonary veins with subsequent clamping. Although routinely performed when completing a totally thoracoscopic surgical ablation technique, 18 this requires the most advanced level of thoracoscopic skill and is most prone to surgical injury to the left atrium and the necessity to convert to thoracotomy/sternotomy or on‐pump surgery. Needless to say, injury requiring conversion is associated with worse outcomes and has been shown to occur in approximately 5% of patients undergoing off‐pump surgical ablation procedures 7 …”