Abstract
Here, we report intermediate follow-up details after using a technique of confluent posterior left atrial wall epicardial ablation designed to eliminate both existing and future atrial fibrillation (AF) substrates. The method is part of the Convergent hybrid procedure for AF ablation. In this study, multiple confluent epicardial ablations with radiofrequency energy were delivered, spanning the vertical and transverse dimensions of the posterior left atrium, along with facilitated pulmonary vein isolation (PVI). Endocardial mapping and ablation were performed to complete PVI and to ablate the cavotricuspid isthmus. All patients were followed clinically and using two-to-four weeks of continuous monitoring at six, 12, and 24 months, respectively. The average length of follow-up was 488 days. Of the 57 largely unselected patients with persistent or longstanding persistent AF (NPAF), mean duration of AF was 5.6 years. Single procedure freedom from AF through 24 months was 64.5%, and that for all arrhythmias, was 58.9%. Sixty-eight percent of patients were off antiarrhythmic drugs. Four patients (7%) required a second endocardial ablation procedure. A sub-analysis of the observed arrhythmia burden present through follow-up showed this to be small (ie, <1%) in the majority of patients involved in this study. In conclusion, the extended posterior left atrial wall ablation technique discussed here, as part of the Convergent hybrid method, achieved notable single-procedure success in a particularly challenging series of patients with NPAF.
Highlights
The field of interventional therapies for non-paroxysmal atrial fibrillation (NPAF) remains encumbered by many challenges
Based on the definitive ‘‘cut and sew’’ technique and a bi-atrial lesion set, irrespective of its efficacy, and including to a lesser degree the Cox IV and Mini-maze procedures, the current-day perception held by many patients, cardiologists, and surgeons is that the invasiveness of these procedures substantially preclude their general adoptability
The comprehensive lesion set we developed differs from other epicardial ablations by directly targeting and encompassing all accessible areas of the posterior left atrium within the oblique sinus, as outlined by the pericardial reflections (Figure 1)
Summary
The field of interventional therapies for non-paroxysmal atrial fibrillation (NPAF) remains encumbered by many challenges. Further obscuring the situation is the impact of patient heterogeneity and the many and varied methods by which procedural outcomes are quantified and characterized. These factors confound the ablation experience and. Confluent Extended Posterior Left Atrial Wall Ablation efforts to explain and verify both successes and failures, and limit comparisons between clinical series. As the interventional experience with NPAF has expanded, the Cox maze III procedure, not curative and often yielding less-than-ideal results in patients with a large left atrium and atrial fibrillation (AF) of extended duration, has maintained credit for the highest and most durable success rate for sinus rhythm.. The optimal procedure and lesion set has yet to be determined
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