Combined epicardial and endocardial ablation for atrial fibrillation: Best practices and guide to hybrid convergent procedures

Abstract

The absence of strategies to consistently and effectively address nonparoxysmal atrial fibrillation by nonpharmacological interventions has represented a long-standing treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to Funding sources: The authors have no funding sources to disclose. Disclosures: Dr Makati serves as a consultant, advisor, and proctor for AtriCure, Boston Scientific, and Medtronic and has received research grants from AtriCure, Boston Scientific, and Medtronic. He serves on speakers bureau for Abbott. Dr Sood serves as a consultant for AtriCure. Dr Lee serves as a consultant for AtriCure. Dr Yang serves as a consultant for AtriCure. Dr Shults serves as a consultant for AtriCure and Medtronic and as a proctor for AtriCure. Dr DeLurgio serves as a consultant for AtriCure, Boston Scientific, and Medtronic and on speakers bureau for AtriCure and Boston Scientific. Dr Gill has received research funding from Abbott and lecture honoraria from AtriCure. Dr Kaba serves as a consultant for AtriCure and Biotronik and on speakers bureau for Daiichi Sankyo and Bayer. Dr Ahsan serves on speakers bureau for AtriCure, Biosense Webster, and Boston Scientific. Dr Lellouche serves as a consultant for Medtronic, Abbott, Boston Scientific, and AtriCure. Dr Blaauw has received department research funding from AtriCure and Medtronic and serves as a proctor for AtriCure, Medtronic, Boston Scientific, and Abbott. Dr Zannis serves as a proctor for AtriCure. Dr Sebag serves as a consultant for AtriCure. Dr Gauri serves as a consultant for Medtronic, IRhythm, and AtriCure. Dr Zembala serves as a proctor for AtriCure and as a consultant for Balton, Abbott, and Boston Scientific.

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

“…One important aspect of both hybrid ablation strategies is a collaborative, heart team approach to patient management in order to optimise clinical outcomes and safely mitigate risks [ 70 ].…”

Left posterior wall: The real key factor in the treatment of persistent atrial fibrillation

“…Indeed, surgical isolation of the LPW has been proved to be durable and effective in improving the freedom from atrial arrhythmias in patients with any kind of clinical presentations of AF 10 . In this regards, the effectiveness of LPWI has been recently highlighted by hybrid approach, in which surgeon and electrophysiologist are side‐by‐side as to achieve the best clinical results in patients with persistent AF 11 . In particular, the hybrid Convergent procedure as a minimally invasive closed‐chest procedure performed on the beating heart that combines epicardial RF ablation—focused on the LPW—followed by complementary endocardial catheter ablation has been proved to significantly reduce the AF burden and improve the clinical outcome of patients with persistent and long‐persistent AF.…”

Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: A systematic review and meta‐analysis

“…During the HCP, epicardial ablation should be the first component. Under endoscopic observation, a closed-irrigation, unipolar RF catheter device is typically utilized for epicardial ablation 30. To access the left atrial posterior wall (LAPW), the device is placed by a pericardioscopic cannula and moved in the pericardial space with the use of the cannula and endoscope.…”

“…Lesions are typically overlapped across the whole LAPW to improve contiguity and transmurality, minimizing gaps and resulting in a uniform zone of electrical silence. Then, the endocardial component complements the epicardial one by touching up the LAPW lesion set if needed based on an electro-anatomic map and by performing additional ablation as required based on the individual patient procedure and clinical characteristics 30.…”