Reply

Abstract

Dr Mahapatra discloses that he has a financial relationship with St. Jude. Dr Mahapatra discloses that he has a financial relationship with St. Jude. We appreciate the letter and interest by Bisleri and colleagues [1Bisleri G. Curnis A. Cheema F.H. Muneretto C. Sequential hybrid ablation for persistent atrial fibrillation (letter).Ann Thorac Surg. 2012; 94: 689-690Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar] regarding our study [2Mahapatra S. LaPar D.J. Kamath S. et al.Initial experience of sequential surgical epicardial-catheter endocardial ablation for persistent and long-standing persistent atrial fibrillation with long-term follow-up.Ann Thorac Surg. 2011; 91: 1890-1898Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar], and we are pleased to reply to their inquiries. Regarding the inquiry related to testing of pulmonary vein (PV) lesions for entrance and exit block, in this series we checked for entrance block of all PV lesions in each patients before and after surgical ablation. In those patients who were in sinus rhythm, or converted to sinus rhythm during the procedure (about 75%), bidirectional block assessment (entrance and exit block from the pulmonary veins) was performed during the surgical procedure, which is thought to be a better indicator for ultimate pulmonary vein isolation. We agree that the placement of the mitral lines is difficult to test. In this initial report, we used this anterior mitral line as described by Edgerton and colleagues [2Mahapatra S. LaPar D.J. Kamath S. et al.Initial experience of sequential surgical epicardial-catheter endocardial ablation for persistent and long-standing persistent atrial fibrillation with long-term follow-up.Ann Thorac Surg. 2011; 91: 1890-1898Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 3Edgerton J.R. Edgerton Z.J. Weaver T. et al.Minimally invasive pulmonary vein isolation and partial autonomic denervation for surgical treatment of atrial fibrillation.Ann Thorac Surg. 2008; 86: 35-38Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar]. We believe that the roof and floor lines when done appropriately will ultimately result in superior outcomes in these patients with persistent or long-standing persistent atrial fibrillation (AF). In this series, we did not perform a transeptal access at the second procedure by the electrophysiologist (EP) unless the patient had inducible AF as described. Although we reported our outcomes with this approach, our current approach has evolved for many of the reasons that these authors cite. Specifically, we routinely perform transeptal access to assess block of all four pulmonary veins as well as the posterior left atrial wall (testing the roof and floor lines). Moreover, the mitral line is now in the typical location, extending from an epicardial lesion from the left inferior pulmonary vein to the coronary sinus and then endocardially and within the coronary sinus if needed. The mitral line is then tested by the EP. Regarding the cavotricuspid isthmus (CTI) ablation, we did perform a cavotricuspid line routinely because we wanted to achieve the best possible outcomes for our patients without the need for repeat ablation given that most patients had a possible history of flutter. At the time we began this study, many centers (including ours) routinely performed CTI line during catheter ablation in patients with persistent AF. Finally, we agree with the authors that lesions can mature and new gaps may open such that a short period of time between the two procedures described here may not be ideal. Clearly the approach should be dependent on referral pattern and be specific to the institution. A delay of 1 month between procedures, while perhaps scientifically more appropriate, adds significantly to the cost to the institution and the cost to the patient to take off additional time from work. Moreover, our referral pattern is such that patients come from several hours away, which makes it unlikely that they would return for additional procedures. Sequential Hybrid Ablation for Persistent Atrial FibrillationThe Annals of Thoracic SurgeryVol. 94Issue 2PreviewWe read with interest the article by Mahapatra and colleagues [1] about their initial experience with a sequential hybrid surgical and electrophysiological approach for the treatment of persistent and long-standing persistent atrial fibrillation. The concept of a hybrid approach combining surgical and electrophysiological (EP) technologies and techniques is intriguing and our group as well has been among the first ones to advocate such strategy [2]. Full-Text PDF