Closed Chest Convergent Epicardial–Endocardial Ablation of Non-paroxysmal Atrial Fibrillation – A Case Series and Literature Review

Abstract

The closed chest convergent procedure is a multidisciplinary approach to atrial fibrillation (AF) treatment. Epicardial posterior left atrial (PLA) ablation is performed by a cardiac surgeon using a transdiaphragmatic endoscope, immediately followed by percutaneous pulmonary vein (PV) isolation performed by a cardiac electrophysiologist. Interim outcomes for the treatment of non-paroxysmal AF (NPAF) were evaluated based on peri-procedural safety and complications, freedom from recurrent AF, and need for cardioversion or repeat catheter ablation at three, six and 12 months post-procedure. A total of 43 patients (86 % NPAF) underwent the convergent procedure. Patients were 84 % male, with mean age 58.6 ± 8.7 years. Mean AF duration was 45.4 ± 40.3 months. Pre-procedure left atrium (LA) volumetric data using cardiac magnetic resonance imaging (MRI) or computed tomography (CT) was available for 30 patients (70 %). Average LA volume was 155.5 ± 48.4 millilitres (ml); two-thirds of patients had a LA volume >130 ml. There was no operative or peri-operative mortality. Sinus rhythm (SR) was recorded at three months in 31 of 39 (79 %) patients, at six months in 24 of 27 (89 %) patients and at 12 months in nine patients. The convergent procedure is a safe and effective option for both PV isolation and PLA substrate ablation in NPAF patients. Long-term follow-up is required and randomised clinical trials warranted.

Convergent epicardial‐endocardial ablation for treatment of long‐standing persistent atrial fibrillation: A review of literature

“…Generally, upon discretion of the surgeon, an esophageal temperature probe can be inserted to minimize risk of atrioesophageal fistula. For the epicardial portion of the ablation, the pericardial space is accessed through a subxiphoid or transdiaphragmatic incision, allowing access to the posterior left atrial wall 9 . A pericardioscopic cannula is inserted through the pericardial window to allow direct access and visualization of the posterior wall 9 .…”

“…For the epicardial portion of the ablation, the pericardial space is accessed through a subxiphoid or transdiaphragmatic incision, allowing access to the posterior left atrial wall 9 . A pericardioscopic cannula is inserted through the pericardial window to allow direct access and visualization of the posterior wall 9 . A unipolar, radiofrequency device is then inserted through the incision to create multiple linear epicardial ablation lines alongside the posterior wall and the regions anterior to the pulmonary veins 10…”

“…CVP is composed of both a thoracoscopically‐performed epicardial ablation of the posterior left atrium and antrum, followed by a standard endocardial pulmonary vein isolation with additional endocardial lesions placed to effect complete antral isolation. The pulmonary vein and posterior left atrial wall can be fully isolated with both endocardial and epicardial ablation lesion 9 . During the endocardial phase of the procedure, the electrophysiologist can confirm the extent to which the posterior left atrium and pulmonary vein have been isolated.…”

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…607,609,613, 1368,1377,1378,1379,1380,1381,1382,1383 This procedure has been largely redesigned to prevent these adverse results, and two papers have reported no mortality and no AEF. 613,1381 …”

Physiological motion modeling for organ‐mounted robots

“…Numerous interventions are possible using these devices, shown in Figure , including cell transplantation, gene therapy for angiogenesis, intrapericardial drug delivery, epicardial electrode placement for resynchronization, epicardial atrial ablation, and ventricle‐to‐coronary artery bypass (VCAB) . Interventions already demonstrated preclinically with these robots include myocardial injection, epicardial pacing, and epicardial ablation…”