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

Abstract

Background and Aim of study The convergent procedure (CVP) is a hybrid ablation technique via a subxiphoid incision that has recently emerged as a treatment option for non‐paroxysmal atrial fibrillation (npAF). By combining endocardial and epicardial ablation into a simultaneous or staged procedure, the pulmonary vein and posterior left atrium can be isolated with transmural lesion sets while minimizing the risk of proarrhythmic gaps that are a known limitation with endocardial linear lesion sets. We reviewed the 12‐month outcomes in patients who underwent CVP compared to those who underwent endocardial catheter ablation (CA) and surgical ablation (SA). Methods A literature search was conducted using the PubMed database for publications related to CVP. Selected studies included detailed 12‐month follow‐up of patients, patient characteristics, periprocedural complications, use of antiarrhythmic drugs (AADs), and monitoring method. Results Five studies with 340 patients who underwent CVP between January 2009 and March 2017 were selected for this review. A total of 8.5% of patients had paroxysmal AF (pAF), 42.2% had persistent AF (peAF), and 49.1% had long‐standing persistent AF (lspAF). At 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs. The overall complication rate was 10%. Conclusion CVP had better 1‐year efficacy in eliminating AF when compared to CA. However, SA, specifically the Cox Maze IV, had lower rates of AF recurrence in the npAF patient population. Despite its promising 1‐year efficacy rates, the periprocedural complication rate for CVP was significantly higher than both CA and SA.

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

“…Our results are consistent with Khan et al, who reported an overall HCP complication rate of 10%. 26 Furthermore, the meta‐analysis by Pearman et al showed no difference between the hybrid procedure and epicardial ablation in the prevention of AA recurrence; moreover, the HCP was associated with higher complication rates (7.3% vs. 2.8%, RR = 2.6). 27 The safety and efficacy of HCP could be potentially affected by the various approaches to the procedure.…”

Robotic-assisted biatrial Cox-maze ablation for atrial fibrillation

“…[3][4][5] Epicardial attempts at minimally invasive ablation, particularly subxiphoid or transdiaphragmatic is often incomplete, does not address the LAA, and may expose to a unique increased set of complications. [6][7][8] Robotic-assisted biatrial surgical ablation can be safely performed as a standalone or concomitant procedure and offers the ability to perform the full Cox-maze III/IV as well as direct LAA obliteration. 9,17 The safety profile and outcomes of robotic surgical ablation may mimic those obtained with sternotomy Cox-maze operations while providing a single-stage, single-incision, minimally invasive procedure to rival alternatives.…”

“…[3][4][5] Furthermore, recent epicardial minimally invasive surgical ablation techniques, particularly subxiphoid, are arrhythmically and antomically incomplete and have potential major safety concerns. [6][7][8] Despite the known effectiveness of the cut-and-sew Coxmaze III, there exists a reluctance on the part of patients, referring cardiologists, and surgeons to carry out a sternotomy for a stand-alone cut-and-sew surgical Cox-maze. Fortunately, the electrophysiologic principles of the Coxmaze III biatrial lesions can be identically and transmurally replicated with alternate power sources consisting of bipolar radiofrequency and/or cryothermia, as the Cox-maze IV procedure (Figure 1).…”

Periods of observation following combined epicardial and endocardial ablation for non‐paroxysmal atrial fibrillation: Navigating the sea of hybrid convergent procedures

“…1 Data on hybrid convergent procedures are mostly single-center observational studies using various techniques. 3,4 Useful end points in comparative reviews have been arrhythmia status, with or without antiarrhythmic drugs, 12-month following the procedure. 3,4 This time point has also been selected for the primary efficacy outcomes of randomized controlled trials.…”

“…3,4 Useful end points in comparative reviews have been arrhythmia status, with or without antiarrhythmic drugs, 12-month following the procedure. 3,4 This time point has also been selected for the primary efficacy outcomes of randomized controlled trials. 2,5,6 Single-center observational studies with small sample sizes are often regarded as pilot studies to set the stage for subsequent re-…”