Correlates of Arrhythmia Recurrence After Hybrid Epi- and Endocardial Radiofrequency Ablation for Persistent Atrial Fibrillation

Abstract

Background-Long-term efficacy of catheter-based treatment of persistent atrial fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently, but their efficacy has never been systematically tested. Methods and Results-Seventy patients (median age, 63.5 years) with persistent atrial fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein isolation, linear ablation, Marshal ligament disruption, and exclusion of the left atrial appendage. The procedure was followed by electroanatomic mapping and ablation (EAM) 2 to 3 months later. Only 76% of patients were in normal sinus rhythm at the beginning of EAM. All 4 pulmonary veins and the left atrium posterior wall were found isolated in 69% and 23% of patients, respectively. Arrhythmia-free survival off antiarrhythmic drugs 12 months after EAM was 77%. Using previously ineffective antiarrhythmic drugs and reablation procedures, arrhythmia free-survival increased to 97% during follow-up (mean, 936±432 days; range, 346-1509 days). The majority of arrhythmia recurrences occurred during the first 12 months after EAM. In a multivariable-adjusted estimates, left atrium volume >165 mL, absent normal sinus rhythm at admission for EAM, and inducibility of any sustained tachyarrhythmia at the end of EAM procedure were identified as independent correlates of atrial fibrillation recurrence. Conclusions-Our report demonstrated that the majority of patients after epicardial ablation, using bipolar radiofrequency instruments, required endocardial catheter ablation to complete the linear ablation lesions and a significant proportion of patients required spot-ablations to complete electric pulmonary vein isolation. Noninducibility of any arrhythmia after a staged hybrid procedure seemed to be the strongest correlate of long-term arrhythmia-free survival.

Hybrid procedures for persistent atrial fibrillation: necessity and timing of the catheter ablation stage

“…Our study (1) and others (9,10) have clearly showed that complete transmural lesions in the left atrium cannot be obtained, in the majority of (let alone all) patients, after an epicardial ablation alone (using bipolar RF energy). The worst outcomes are more associated with left atrial linear lesions compared to PV isolations.…”

“…If we adopt the paradigm that durable PV isolation is the major factor precluding arrhythmia recurrence during longterm follow-up of patients after epicardial RF ablation, then based on our results, we should draw the conclusion that omitting endocardial catheter ablation after surgery would result in at least a 30% arrhythmia recurrence rate, which corresponds to the PV reconnection rate seen in our study (1). Extending this assumption to linear lesions (box lesion, trigone line) would lead to an arrhythmia recurrence rate of at least 70%.…”

Staged hybrid procedure in persistent atrial fibrillation: safety, efficacy, and atrial tachyarrhythmia

“…It could raise a question whether endocardial ablation of certain lines, including cavo-tricuspid-isthmus, is necessary before the window period. Accordingly, we changed the timing of endocardial procedure from an early stage (5 days after surgery) to three months after the surgery (window period), in line with a previously published paper (15). However, we perform staged hybrid procedure in patients with atrial tachyarrhythmia only despite epicardial ablation.…”

“…We read the paper of Bulava et al regarding the correlation of arrhythmia recurrence after hybrid epicardial and endocardial radiofrequency ablation for persistent atrial fibrillation with great interest (15). We would like to discuss the results regarding: (I) safety of thoracoscopic epicardial ablation; (II) timing of post-procedural endocardial electrophysiological confirmation; (III) recurrent atrial tachyarrhythmia after epicardial thoracoscopic ablation.…”

Year in Review in Cardiac Electrophysiology

“…In a study published last year, 21 70 patients with persistent AF underwent minimally invasive epicardial surgery for AF followed by catheter-based electroanatomic mapping and ablation 2 to 3 months later. The majority of patients after epicardial ablation were found to require additional endocardial catheter ablation to complete the ablation sets.…”