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Transvenous Before Surgical Hybrid Procedure
Joseph J Tiano1, Robert Drennan2, John Novella1
1St. Vincent's Medical Center - Bridgeport, Connecticut.
Insights
The novel endocardial-before-epicardial ablation strategy successfully managed persistent atrial fibrillation (PeAF) and long-standing persistent atrial fibrillation (LSPeAF) in all patients. This approach offers a promising alternative for treating complex atrial arrhythmias.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Persistent atrial fibrillation (PeAF) and long-standing persistent atrial fibrillation (LSPeAF) present significant management challenges.
- Conventional and hybrid ablation approaches have shown limited clinical success in treating these complex arrhythmias.
Purpose of the Study:
- To evaluate the efficacy and safety of a novel endocardial-before-epicardial ablation strategy for PeAF and LSPeAF.
- To describe the comprehensive endovascular and epicardial procedures involved in this approach.
Main Methods:
- A single-center study followed 40 patients with PeAF/LSPeAF over 12 months.
- The procedure involved an endovascular phase (pulmonary vein isolation, linear lesions, CFAE ablation) followed by an epicardial phase (GP ablation, posterior wall ablation, LAA ligation).
- All patients received implantable cardiac monitoring.
Main Results:
- All 40 patients maintained sinus rhythm at 12-month follow-up.
- Documented episodes of paroxysmal atrial arrhythmias did not persist after oral antiarrhythmic medication discontinuation.
- No procedural complications were reported.
Conclusions:
- The endocardial-before-epicardial approach significantly improved the management of PeAF and LSPeAF compared to conventional methods.
- This strategy demonstrates a promising, complication-free option for managing complex atrial arrhythmias.
Background:
Historically, persistent atrial fibrillation (PeAF) and long standing persistent atrial fibrillation (LSPeAF) have demonstrated limited clinical success despite hybrid approaches.
Objective:
We describe our experience with the endocardial-before-epicardial approach defined by a comprehensive endovascular approach preceding and guiding the epicardial approach which includes an extensive posterior wall ablation.
Methods:
40 patients were followed over a 12 month period. The procedure was performed in a single center. Patients had a mean duration of atrial fibrillation of 6.0 ± 4.5 years with 22.5% having undergone prior ablations. Mean age was 61.7 ± 7.9 years with a mean left atrial volume of 131.5 ± 46.9 mL. The endovascular procedure remained uniform with antral pulmonary vein isolation, posterior left atrial roof and right atrial cavo-tricuspid isthmus (CTI) linear lesions with mapping and ablation of left atrial complex electrograms (CFAEs) and prior existing atrial arrhythmias. The epicardial procedure included a thorascopic approach with ganglionated plexus (GP) mapping and ablation, left atrial posterior wall ablation, directed CFAE ablation and left atrial appendage ligation. All patients received implantable cardiac monitoring.
Results:
All 40 patients remained in sinus rhythm at their 12 month follow-up. During the monitoring period, episodes of paroxysmal atrial arrhythmias including fibrillation were documented, without persistence, after discontinuation of oral antiarrhythmic medications.
Conclusion:
The endo-before-epi approach resulted in improved management of persistent and long standing persistent atrial fibrillation over reported results for conventional approaches with no procedural complications, making this a promising option for the management of these arrhythmias.
