New Technologies and Hybrid Surgery for Atrial Fibrillation

Abstract

The Cox maze III and Cox maze IV procedures are surgical solutions for the treatment of symptomatic stand-alone atrial fibrillation. Despite their proven efficacy, these procedures have not gained widespread acceptance because of the invasiveness, complexity, and technical difficulty. Endocardial pulmonary vein isolation is the cornerstone of percutaneous catheter ablation for atrial fibrillation. It is currently accepted as an invasive therapy, if rhythm control has failed using antiarrhythmic drugs or electrical cardioversions. Pulmonary vein isolation is reported to be effective in 60%–85% of patients with paroxysmal atrial fibrillation and in 30%–50% of patients with persistent atrial fibrillation. A second or third ablation is often necessary to achieve these results, and complications may occur in up to 6% of patients.Surgical treatment of atrial fibrillation has seen important improvements in the last decade. New technologies have simplified creation of transmural lesions on the beating heart through a less-invasive, thoracoscopic procedure. This allows for pulmonary vein isolation, isolation of the posterior wall, and left atrial appendage exclusion—usually combined with ganglionic plexi evaluation and destruction. Nonetheless, it is still uncertain whether these procedures are effective in restoring permanent sinus rhythm since transmurality of a lesion set cannot be guaranteed with current ablation catheters on the beating heart.In an attempt to limit the shortcomings of an endo- or an epicardial technique, a hybrid approach has recently been introduced. This approach is based on a close collaboration between the surgeon and the electrophysiologist, employing a patient-tailored procedure which is adapted to the origin of the patient’s atrial fibrillation and takes into consideration triggers and substrate. Using a mono- or bilateral energy source, a thoracoscopic epicardial approach is combined with a percutaneous endocardial ablation in a single-step or in a sequential-step procedure.This article provides our experience and an overview of the current knowledge in the hybrid treatment of stand-alone atrial fibrillation.

Hybrid ablation for atrial fibrillation: a systematic review

“…Five groups used a bilateral thoracic approach [27, 38, 40, 41, 46], three groups used a right thoracic monolateral approach [34, 35, 39], one used a subxiphoideal approach [42], and two others used a transabdominal transdiaphragmatic approach [36, 37]. The group of Pison et al [15, 23, 32] used bilateral, left and right monolateral thoracoscopic approaches. Gaita et al [43] was the only group to perform open hybrid surgery, combined with valve or coronary surgery.…”

“…However, with a right-sided approach it is more difficult to occlude or exclude the LAA. In case of a left-sided approach, it is possible to isolate the right PVs using the standard bipolar devices, which would not be possible the other way around [23]. To reach the left PVs using a right thoracoscopy, an ablation probe delivering continuous lesions encircling the origin of all PVs and the posterior aspect of the LA all together, creating a box lesion, is needed [34, 35, 39].…”

Sequential Hybrid Procedure for Persistent Atrial Fibrillation

“…Surgical treatment of AF has shifted from open heart surgery and cut‐and‐sew techniques toward minimally invasive procedures using endoscopic instruments to isolate the PVs, create linear lesions, and occlude the left atrial appendage (LAA)—all on the beating heart. 7 Although this approach achieves higher arrhythmia‐free success rates after a single procedure than catheter ablations, 8 contiguous and transmural lesions cannot always be guaranteed. 9 The mitral isthmus and the tricuspid isthmus lines are particularly difficult to ablate from the epicardial surface of the heart.…”

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

“…The Dallas lesion set makes a trigone line instead of the traditional mitral isthmus line, and it has approached the outcomes of the Cox-maze procedure without including right atrial lesions (10,11). The hybrid approach of the two methods, which are complementary, provide an alternative approach (12)(13)(14). The Expert Consensus says that whereas persistent atrial fibrillation patients might not have been candidates for catheter ablation preoperatively, they are now ideal candidates for a "touch-up" catheter ablation after surgical ablation.…”