Stepwise endo‐/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach

Abstract

Background: Outcomes of catheter ablation (CA) among patients with nonparoxysmal atrial fibrillation (AF) are largely disappointing.Objective: We sought to evaluate the feasibility, effectiveness, and safety of a single-stage stepwise endo-/epicardial approach in patients with persistent/ longstanding-persistent AF.Methods: We enrolled 25 consecutive patients with symptomatic persistent (n = 4) or longstanding-persistent (n = 21) AF and at least one prior endocardial procedure, who underwent CA using an endo-/epicardial approach. Our anatomical stepwise protocol included multiple endocardial as well as epicardial (Bachmann's bundle [BB] and ligament of Marshall ablations) components, and entailed ablation of atrial tachycardias emerging during the procedure. The primary outcome was freedom from any AF/atrial tachycardia episode after a 3-month blanking period. The secondary outcome was patients' symptom status during follow-up.Results: The stepwise endo-/epicardial approach allowed sinus rhythm restoration in 72% of patients, either directly (n = 6, 24%) or after AF organization into atrial tachycardia (n = 12, 48%). BB's ablation was commonly implicated in arrhythmia termination. After a median follow-up of 266 days (interquartile range, 96 days), survival free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be discontinued in 22 patients (88%). As compared to baseline, more patients were asymptomatic at 9-month follow-up (0% vs. 56%, p = .02). Five patients (20%) developed mild medical complications, whereas one subject (4%) had severe kidney injury requiring dialysis. Conclusion:A single-stage endo-/epicardial CA resulted in favorable rhythm and symptom outcomes in a cohort of patients with symptomatic persistent/ This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

One-Year Outcomes of the Mediterranea Technique for Longstanding Persistent Atrial Fibrillation

“…In our work, we provided the first description of a novel stepwise approach for longstanding persistent AF, the Mediterranea technique, which critically differs from previously proposed procedures in that it incorporates epicardial ablation of epicardial arrhythmogenic structures (namely, the Bachmann's bundle and the ligament of Marshall). 1 In our first report, we were only able to enroll a limited number of patients (n=25) and to follow them for approximately nine months, therefore our work may well be considered a pilot study. 1 At the prespecified one-year follow-up appointment, we did not observe any further recurrences, so that freedom from arrhythmia recurrences measured 88% (22 out of 25) after approximately 12 months.…”

“…1 In our first report, we were only able to enroll a limited number of patients (n=25) and to follow them for approximately nine months, therefore our work may well be considered a pilot study. 1 At the prespecified one-year follow-up appointment, we did not observe any further recurrences, so that freedom from arrhythmia recurrences measured 88% (22 out of 25) after approximately 12 months. Therefore, our results seem very promising when compared to other hybrid techniques mainly involving posterior wall isolation.…”

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

“…Periods of observation following combined epicardial and endocardial ablation for non-paroxysmal atrial fibrillation: Navigating the sea of hybrid convergent procedures De Martino et al reported their experience with a stepwise endocardial and epicardial catheter ablation strategy for treatment of non-paroxysmal atrial fibrillation (AF) using a single-center, singlearm prospective cohort design. 1 Named the Mediterranea approach, it resulted in 22 of 25 (88%) patients experiencing freedom from any AF or atrial tachycardia, excluding the 3-month postablation "blanking period," after a median follow-up of 266 days (interquartile range, 96 days). The primary effectiveness outcome was analyzed using the Kaplan-Meier method and, consequently, did not incorporate a prespecified time point for assessment of arrhythmia status.…”

“…Investigators concluded their approach "resulted in restoration and maintenance of sinus rhythm in the majority of patients at 9month follow-up." 1 As illustrated in survival curves presented in the CONVERGE trial, which assessed 12-month outcomes after hybrid convergent procedures where unipolar radiofrequency devices (EPi-Sense; AtriCure) were used for epicardial ablation, the 9-month time point corresponds to follow-up day 275. 2 Therefore, in the published article, the majority of patients that received the Mediterranea approach had not yet reached the 9-month postablation time point.…”

“…2 Therefore, in the published article, the majority of patients that received the Mediterranea approach had not yet reached the 9-month postablation time point. 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.…”