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Stepwise endo-/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach
Giuseppe De Martino1, Paolo Compagnucci2, Carmine Mancusi1
1Arrhythmology and Heart Failure Unit, Mediterranea Hospital, Naples, Italy.
Insights
A novel catheter ablation technique combining endocardial and epicardial approaches improved rhythm control and symptoms in patients with persistent atrial fibrillation (AF). This stepwise strategy, including Bachmann's bundle ablation, showed promising results for difficult AF cases.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Outcomes of catheter ablation (CA) for nonparoxysmal atrial fibrillation (AF) are often unsatisfactory.
- Persistent and longstanding-persistent AF present significant treatment challenges.
Purpose of the Study:
- To evaluate the feasibility, effectiveness, and safety of a single-stage, stepwise endocardial/epicardial approach for AF.
- To assess rhythm control and symptom improvement in patients with persistent/longstanding-persistent AF undergoing this combined ablation strategy.
Main Methods:
- A cohort of 25 patients with symptomatic persistent/longstanding-persistent AF and prior endocardial procedures underwent CA.
- The protocol involved a stepwise endocardial and epicardial approach, including Bachmann's bundle and ligament of Marshall ablations.
- Atrial tachycardias emerging during the procedure were also ablated.
Main Results:
- Sinus rhythm was restored in 72% of patients, with Bachmann's bundle ablation frequently contributing to arrhythmia termination.
- Freedom from AF/atrial tachycardia after a 3-month blanking period was 88% at a median follow-up of 266 days.
- Significant symptom improvement was observed, with 56% of patients becoming asymptomatic, and antiarrhythmic drugs were discontinued in 88%.
Conclusions:
- A single-stage endo-/epicardial CA approach offers favorable rhythm and symptom outcomes in patients with challenging persistent/longstanding-persistent AF.
- Epicardial ablation of Bachmann's bundle is a key component for procedural success in this patient group.
- The combined approach demonstrates safety and efficacy, with a low rate of mild complications and one severe event.
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/longstanding-persistent AF and one or more prior endocardial procedures. Epicardial ablation of BB was commonly implicated in procedural success.
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