Convergent Procedure Research Articles

Revolutionizing Atrial Fibrillation Treatment: The Robotic Convergent Plus Procedure.

Atrial fibrillation (AF) is widely accepted to be the most common sustained arrhythmia, with an increasing incidence over time. This is thought to be due to the aging population across the world. AF occurs when abnormal electrical foci result in disorganization of atrial depolarization, though the exact pathophysiology leading to these abnormal foci is not well understood. A range of interventions exist for AF - pharmacological therapies (anti-arrhythmic or negative chronotropic medications), cardioversion, or ablations to interrupt the abnormal conduction pathways. Ablation may be via a catheter-based approach, via a surgical approach using the "Maze" procedure (Cox-Maze IV), or more recently, via a hybrid approach. This first involves a surgical epicardial ablation, with catheter-based endocardial ablation following a few weeks later to ensure durable transmural lesion sets via the "Convergent" procedure. We describe the use of the Da Vinci Xi™ robotic platform to improve the procedure, allowing continuous and improved visualization of the anatomy without the need for potentially harmful retraction of the atrial appendage or the back of the left atrium, as well as increased precision with our mapping tools and more complete ablation. Here, we highlight the advantages over a non-robotic (subxiphoid) Convergent procedure, while outlining the key operative steps in undertaking the "Robotic Convergent Plus" procedure using the Da Vinci Xi™ robotic surgical system.

Robotic-Assisted Epicardial Hybrid Ablation and Left Appendage Closure in Persistent Atrial Fibrillation: First European Experience.

Background: Pulmonary vein isolation is currently considered to be the gold standard for ablating paroxysmal atrial fibrillation. However, its efficacy is limited in patients with persistent atrial fibrillation. The convergent procedure has emerged as a hybrid ablation. This study aims, for the first time in the literature, to introduce a hybrid approach that includes epicardial ablation with cutting-edge robotic technology and subsequent electrophysiological study to verify and an endocardial ablation to complete the ablation lines. Methods: We present 18 cases of robotic-assisted epicardial hybrid ablation performed between April and December 2023 on patients with long-standing persistent atrial fibrillation (mean age: 64 ± 5 years; mean duration: 4 ± 2 years). All of the procedures were performed at "Humanitas Gavazzeni Hospital", Bergamo, Italy. Robot-assisted epicardial ablation performed using the "Epi-Sense AtriCure" device was guided by monitoring electrogram morphology and point-by-point impedance drop. This approach also included left atrial appendage occlusion and the disconnection of the ligament of Marshall. An electrophysiological study and endocardial ablation were planned three months after the procedure. Results: The procedure was successfully executed in all patients with no major complications and a mean operative time of 142 ± 22 min. None of the cases required conversion to full sternotomy or minithoracotomy. The procedure was performed in all cases without extracorporeal circulation and on a beating heart. Fifteen patients (83%) were extubated in the operating room. The length of stay in the intensive care unit was less than 24 h. Acute restoration of sinus rhythm was achieved in 12 out of the 18 patients (67%); the median duration of their hospital stay was two days. In the electrophysiological study, seven pts had sinus rhythm, two had atrial fibrillation, and one patient developed atrial flutter at 3-month follow-up. Patients underwent transcatheter ablation to complete the lesion set and, at the time of discharge, were all in sinus rhythm. Conclusions: In our initial experience, surgical atrial fibrillation ablation consisting of a unilateral thoracoscopic technique facilitated by a robotic platform and continuous EGM monitoring has proven to be safe and feasible. For the electrophysiological study at 3 months, completing the gaps in the surgical ablation lines could improve the clinical results of the technique in terms of sinus rhythm stability. However, mid- and long-term follow-up is required to demonstrate this.

Atrial fibrillation symptom reduction and improved quality of life following the hybrid convergent procedure: a CONVERGE trial subanalysis.

CONVERGE was a prospective, multicenter, randomized controlled trial that evaluated the safety of Hybrid Atrial Fibrillation Convergent (HC) and compared its effectiveness to endocardial catheter ablation (CA) for the treatment of persistent atrial fibrillation (PersAF) and longstanding PersAF (LSPAF). In 2020, we reported that CONVERGE met its primary safety and effectiveness endpoints. The primary objective of the present study is to report CONVERGE trial results for quality of life (QOL) and Class I/III anti-arrhythmic drug (AAD) utilization following HC. Eligible patients had drug-refractory symptomatic PersAF or LSPAF and a left atrium diameter ≤6.0 cm. Enrolled patients were randomized 2:1 to receive HC or CA. Atrial Fibrillation Severity Scale (AFSS) and the 36-Item Short Form Health Survey (SF-36) were assessed at baseline and 12 months; statistical comparison was performed using paired t-tests. AAD utilization at baseline through 12 and 18 months post-procedure was evaluated; statistical comparison was performed using McNemar's tests. A total of 153 patients were treated with either HC (n=102) or CA (n=51). Of the 102 HC patients, 38 had LSPAF. AFSS and SF-36 Mental and Physical Component scores were significantly improved at 12 months versus baseline with HC overall and for the subset of LSPAF patients treated with either HC or CA. The proportion of HC patients (n=102) who used Class I /III AADs at 12 and 18 months was significantly less (33.3% and 36.3%, respectively) than baseline (84.3%; P<0.001). In LSPAF patients who underwent HC (n=38), AADs use was 29.0% through 18 months follow-up versus 71.1% at baseline (P<0.001). HC reduced AF symptoms, significantly improved QOL, and reduced AAD use in patients with PersAF and LSPAF. NCT01984346.

Development and validation of nursing students' moral sensitivity questionnaire in Taiwan.

Ethical literacy is a critical aspect of professional nursing development. It is considered an essential quality that nursing professionals should possess throughout their careers. Moral sensitivity serves as the foundation for developing ethical literacy. The objective of this study was to develop a reliable tool for assessing moral sensitivity among nursing students. The questionnaire was developed following a rigorous approach, consisting of three stages process, combining the Schwartz-Barcott and Kim hybrid model of concept development with the methodology suggested by Devellis and Waltz. A total of 297 nursing students (287 females, 10 males; mean age: 18.7 years) participated in the study, with five invalid questionnaires excluded from the analysis. The questionnaire's reliability was established through internal consistency and test-retest reliability analyses. Furthermore, the moral sensitivity questionnaire for nursing students demonstrated satisfactory validity through the results of construct, convergent and discriminant validation procedures. The study findings revealed a significant correlation between the internship performance of students and their overall moral sensitivity score. The questionnaire would be appropriated to be included as a supplemental measure for ethical literacy evaluation.

Surgery for Cardiac Arrhythmias: Past, Present, Future.

There is a rich history of surgery for cardiac arrhythmias, spanning from atrial fibrillation and Wolff-Parkinson-White syndrome to inappropriate sinus tachycardia and ventricular tachycardia. This review describes the history of these operations, their evolution over time, and the current state of practice. We devote considerable time to the discussion of atrial fibrillation, the most common cardiac arrhythmia addressed by surgeons. We discuss ablation of atrial fibrillation as a stand-alone operation and as a concomitant operation performed at the time of cardiac surgery. We also discuss the emergence of newer procedures to address atrial fibrillation in the past decade, such as the convergent procedure and totally thoracoscopic ablation, and their outcomes relative to historic approaches such as the Cox maze procedure.

Design, synthesis, and biological investigation of selective human carbonic anhydrase II, IX, and XII inhibitors using 7-aryl/heteroaryl triazolopyrimidines bearing a sulfanilamide scaffold

A novel library of human carbonic anhydrase (hCA) inhibitors based on the 2-sulfanilamido[1,2,4]triazolo[1,5-a]pyrimidine skeleton modified at its 7-position was prepared by an efficient convergent procedure. These derivatives were evaluated in vitro for their inhibition properties against a representative panel of hCA isoforms (hCA I, II, IV, IX, and XII). The target tumour-associated isoforms hCA IX and XII were potently inhibited with KIs in the low nanomolar range of 5–96 nM and 4–72 nM, respectively. Compounds 1d, 1j, 1v, and 1x were the most potent hCA IX inhibitors with KIs of 5.1, 8.6, 4.7, and 5.1 nM, respectively. Along with derivatives 1d and 1j, compounds 1r and 1ab potently inhibited hCA XII isoform with KIs in a single-digit nanomolar range of 8.8, 5.4, 4.3, and 9.0 nM, respectively. Compounds 1e, 1m, and 1p exhibited the best selectivity against hCA IX and hCA XII isoforms over off-target hCA II, with selectivity indexes ranging from 5 to 14.

A new procedure for rapid convergence in numerical performance calculations of electrochemical cells

This paper introduces a novel coupled region-to-region numerical procedure for electric field potential calculations. A conventional segregated scheme is also introduced to illustrate the coupling issues that exist in performance calculations in electrochemical devices. Numerical simulations are conducted for a solid oxide cell operating in both fuel cell and electrolysis modes. The cell performance is predicted with both segregated and coupled methods. A comparison between the coupled and segregated schemes shows that the former greatly outperforms the latter, reducing convergence times (from 5000 to 300 iterations) and improving stability. A smaller coupling coefficient contributes to the convergence as well, however, less markedly. The coupled region-to-region approach may readily be applied to numerous other scenarios, e.g., heat transfer problems between multiple phases and regions.

Iterative decoupling procedure for the coupled 1D problems on example of closed cylindrical shell at static loading

The general iterative method of formal decoupling of two coupled 1D problems is suggested. Its essence consists in the alternative consideration of one of two problems as the main one, the aim of which is to produce the eigenfunctions. Then the other problem is considered as an auxiliary one, which is aimed to obtain the particular solution. The latter is presented as a linear combination of already known eigenfunctions, and then is substituted again into the first problem to refine the constants of main governing differential equation and to get the corrected eigenfunctions. The convergent iterative procedure of gradual refinement of the above constants is elaborated. The accuracy and technique of application is considered in details for the closed cylindrical shell problem, which is expanded in Fourier series with respect to circumferential coordinate. This actually leads to coupled 1D problems – one is the plane elasticity problem, and other – the plate problem. The results of calculation show the high accuracy of the method, which allows to get any required number of significant digits in eigenvalues. The comparison with known theoretical and FEM results for radial displacement and axial bending moment distribution at the vicinity of point of concentrated radial force application demonstrates the efficiency and accuracy of the method.

Toward the use of LES for industrial complex geometries. Part I: automatic mesh definition

With the constant increase of computational power for the past years, Computational Fluid Dynamics (CFD) has become an essential part of the design in complex industrial processes. In this context, among the scale resolving numerical methods, Large-Eddy Simulation (LES) has become a valuable tool for the simulation of complex unsteady flows. To generalise the industrial use of LES, two main limitations are identified. First, the generation of a proper mesh can be a difficult task, which often relies on user-experience. Secondly, the ‘time-to-solution’ associated with the LES approach can be prohibitive in an industrial context. In this work, these two challenges are addressed in two parts. In this Part I, an automatic procedure for mesh definition is proposed, whereas the Part II is devoted to numerical technique to reduce the LES ‘time-to-solution’. The main goal of these works is then to develop an accurate LES strategy at an optimised computational cost. Concerning the mesh definition, because LES is based on separation between resolved and modelled subgrid-scales, the quality of the computed solution is then directly linked to the quality of the mesh. However, the definition of an adequate mesh is still an issue when LES is used to predict the flow in an industrial complex geometry without a priori knowledge of the flow dynamics. This first part presents a user-independent approach for both the generation of an initial mesh and the convergence of the mesh in the LES framework. An automatic mesh convergence strategy is proposed to ensure LES accuracy. This strategy is built to guarantee a mesh-independent mean field kinetic energy budget. The mean field kinetic energy is indeed expected to be mesh independent since only turbulent scales should be unresolved in LES. The approach is validated on canonical cases, a turbulent round jet and a turbulent pipe flow. Finally, the PRECCINSTA swirl burner is considered as a representative case of complex geometry. First, an algorithm for the generation of an unstructured mesh from a STL file is proposed to generate a coarse initial mesh, before applying the mesh convergence procedure. The overall strategy including automatic first mesh generation and its automatic adaptation paves the way to use LES approach as a decision support tool for various applications, provided that the ‘time-to-solution’ is compatible with the applications constraint. A second paper, referred as Part II, is devoted to the reduction of this time.

Data envelopment analysis of two‐stage processes: an alternative (non‐conventional) approach

AbstractNetwork data envelopment analysis (NDEA) is an extension of standard DEA that models the efficiency assessment of decision‐making units (DMUs) by considering their internal structure. While in standard DEA, the DMU is regarded as a single process, in NDEA, the DMU is viewed as a network of interconnected sub‐processes (stages, divisions), where the flow of the intermediate products (measures) is essential in the efficiency assessment. In the prevalent conventional methodological approach to NDEA, the sub‐processes are assumed as distinct entities with distinct inputs and outputs. Thus, each sub‐process has its own production possibility set (PPS), which can be derived axiomatically from a set of assumptions using the minimum extrapolation principle. The PPS of the overall system is defined as the composition of the individual PPSs. The conventional approach comprises all the methods, in which the system and the divisional efficiencies are computed jointly in a single mathematical program. A fundamental property connecting the system with the divisional efficiencies is that a system is overall efficient if and only if its divisions are all efficient. In NDEA, regardless of the method used, there are cases where none of the observed DMUs is rendered overall efficient as corroborated by real‐world case studies. This is the main issue we discuss in this paper and the motivation to propose an alternative, non‐conventional, approach to address it in the frame of two‐stage processes. We consider the two‐stage process as a system that can be viewed from two perspectives depending on the role of the intermediate measures: the system as producer and as consumer of the intermediates. As our approach is based on standard DEA, it satisfies the basic desirable properties. The fundamental NDEA property, that the overall system is efficient if and only if both perspectives are efficient, is met. The efficient frontier of the system is explicitly defined by the overall efficient observed DMUs, and the inefficient DMUs are projected on the efficient frontier of the system. A convergent procedure is presented for this purpose. The proposed models are equivalently expressed in both the multiplier and the envelopment forms due to strict primal‐dual correspondence and can operate under both constant and variable returns‐to‐scale assumptions. We use the case of 22 automotive manufacturers for the fiscal year 2019 as an example to illustrate our approach. Comparison with other NDEA methods is also provided.

Towards high-throughput many-body perturbation theory: efficient algorithms and automated workflows

The automation of ab initio simulations is essential in view of performing high-throughput (HT) computational screenings oriented to the discovery of novel materials with desired physical properties. In this work, we propose algorithms and implementations that are relevant to extend this approach beyond density functional theory (DFT), in order to automate many-body perturbation theory (MBPT) calculations. Notably, an algorithm pursuing the goal of an efficient and robust convergence procedure for GW and BSE simulations is provided, together with its implementation in a fully automated framework. This is accompanied by an automatic GW band interpolation scheme based on maximally localized Wannier functions, aiming at a reduction of the computational burden of quasiparticle band structures while preserving high accuracy. The proposed developments are validated on a set of representative semiconductor and metallic systems.

Boundary-Value Problems for the System of Operator-Differential Equations in Banach and Hilbert Spaces

We establish necessary and sufficient conditions for the existence of solutions of linear and nonlinear boundary-value problems in Hilbert and Banach spaces and present a convergent iterative procedure for finding the solutions in the nonlinear case.

PO-02-077 HYBRID CONVERGENT PROCEDURE FOR THE TREATMENT OF PERSISTENT AND LONG-STANDING PERSISTENT ATRIAL FIBRILLATION: A SINGLE CENTER EXPERIENCE

Pulmonary vein isolation by endocardial ablation is an effective treatment strategy for paroxysmal atrial fibrillation (AF). However, its effectiveness for treatment of persistent forms of AF is limited. In patients with advanced AF, there are extra-pulmonary vein foci that initiate and perpetuate AF. The left atrial posterior wall has been shown to have the highest proportion of such triggers. The Hybrid Convergent procedure is a novel procedure that combines epicardial and endocardial ablation to obtain isolation of the left atrial posterior wall and pulmonary veins. There is paucity of real world and long-term outcomes data regarding the Hybrid Convergent procedure. The purpose of this study is to describe the outcomes of Hybrid Convergent procedures for treatment of persistent and long standing persistent atrial fibrillation at 1 and 3 year follow up. A retrospective review of prospectively maintained single center Hybrid Convergent database was performed. Demographics, clinical, procedural, and outcomes data were collected on all patients. Atrial fibrillation burden was tracked using ECGs, wearable monitors, ICDs/pacemakers, implantable recorders and Holter monitors. Fifty patients with persistent and long-standing persistent AF underwent Hybrid Convergent procedure (age 62.6 ±9.1; male: 78%). Prior to ablation, the mean number of failed antiarrhythmic drugs was 2.3, mean number of previous ablations was 1.7, and mean left atrial volume index was 47.5 ± 17.9 ml/m2. 29 of 41 (71%) patients were free from AF recurrence at one year and 16 of 32 (50%) were free from AF at 3 years. The mean pre-operative AF burden for the group was 65.6 ± 40.2% on antiarrhythmics. Postoperatively, the total AF burden at 1 and 3 years were 23. 8 ± 40.9%, and 27.9 ± 41.1%, respectively. The Hybrid Convergent procedure is effective for the treatment of persistent and long-standing persistent AF with a 1- and 3-year freedom from AF recurrence of 71% and 50%, respectively. In this patient population, this procedure was able to reduce the mean burden of AF by 63.7% (41.8% absolute) at 1 year and by 57.4% (37.7% absolute) at 3 years. Our single center experience is consistent with the success rate from the Converge randomized trial at one year and provides additional 3 year follow up data.

PO-04-009 A UNIQUE CASE OF POST-LARIAT LEAK COIL EMBOLIZATION IN A PATIENT WITH NITINOL ALLERGY

Nickel allergy is quite common. The predominant component of nitinol is nickel. Nickel allergy is rare in clinical practice but well established. Most closure devices for the LAA employ nitinol. Lariat ligation of the LAA avoids exposure to nitinol. The incidence of post-lariat leak is variable in the reported literature. Central leaks occur in epicardial devices due to the gunny sack effect. We report a unique case of central leak coil embolization in a patient with a nitinol allergy. In patients with a nickel or nitinol allergy, the use of multiple steel coils to close left atrial appendage closure leaks is feasible and can avoid allergen exposure. N/A A 70-year-old female with a past medical history of atrial fibrillation and atrial flutter s/p endocardial ablation with recurrence. The patient underwent convergent procedure modified with a lariat as the patient had a nitinol allergy. Postoperative TEE revealed the presence of an 8 mm x 4 mm flow in the LAA (Fig 1). The patient later returned leak embolization. A vascular occluder could not be used given the nitinol allergy. Thus, seven platinum coils (60 cmx2, 40 cmx2, 35 cmx2, and 30 cm) (Penumbra, Alameda, CA, USA). Leak closure was subsequently confirmed using TEE and fluoroscopy (Figure). The patient has done well post procedure and is now off oral anticoagulants. The incidence of post-LAAC leak reported in available literature is highly variable. Central leaks occur in epicardial devices due to the gunny sack effect, whereas peripheral leaks occur in endocardial devices due to lack of edge opposition. Just like LAA occlusion or closure, most options for leak closure require exposure to nitinol. A vascular occluder which would ordinarily be used contains nitinol. Radiofrequency ablation requires contact to endocardium and thus not an option for a central leak of this size.

Language Learning Investment in Higher Education: Validation and Implementation of a Likert-Scale Questionnaire in the Context of Compulsory EFL Learning

Second language learning investment relates to the willingness and effort of learners to develop language competencies which will give them a good return in terms of personal or professional benefits. Research has often explored learning investment through learners in the target language context or language teachers. This study, however, explores learning investment with undergraduate learners who are obligated to learn English as a foreign language, regardless of their future profession. To this end, a Likert-scale questionnaire was first designed to examine four investment dimensions which have been identified in previous qualitative research: motivation, necessity, engagement and agency. For validity and reliability purposes, the questionnaire was administered to six second language research professors and 41 students who completed three compulsory English courses in a BA in Inclusive Education. Content, construct and convergent validity procedures were implemented to test the investment dimensions. Regarding reliability, equivalent forms were used to check the stability of answers and to avoid primacy and fatigue effects. In addition, internal consistency and inter-item correlations were checked through Cronbach Alpha coefficients. After the validity and reliability procedures, the four dimensions of learning investment were explored among the language learners. The statistical analyses revealed favorable motivation and engagement results. Nonetheless, they raised some concerns regarding necessity and agency.

Detection and Reporting of Wireless Channel Congestion and Interference in Connected Vehicle Networks

Connected vehicle (CV) wireless networks based on dedicated short-range communications (DSRC), European Telecommunications Standards Institute (ETSI) intelligent transportation systems (ITS-G5), and C-V2X technologies are susceptible to interference from both unintentional emitters and non-CV devices that may be authorized to share the same or adjacent bands. Such interference may lead to unreliable communication and disruption of CV services with a particular impact on safety-related applications. Surprisingly, considering the safety-critical nature of CV applications, there is no simple mechanism for detecting congestion or interference in such networks over wide areas. To address this gap, we propose and demonstrate that both interference and congestion in DSRC and ETSI ITS-G5 networks can be detected simply and inexpensively using capabilities that are already incorporated into the IEEE 802.11p standard, specifically the flags and statistics generated mostly in the physical layer (physical layer convergence procedure and physical medium dependent) state machines. Such a capability could be realized through a relatively minor software upgrade but would resolve a longstanding but underappreciated concern that CV networks are vulnerable to both congestion and a variety of short-range interferers but lack the capability to detect or report this. Although our focus was on DSRC and ITS-G5, similar considerations apply to related schemes such as C-V2X.

Application of an Automatic Mesh Convergence Procedure for the Large Eddy Simulation of a Multipoint Injection System

AbstractLean combustion is an attractive alternative to limit pollutants levels in order to meet the imposed limitations for the next generation of civil aero-engines. However, its implementation involves important technological questions related to the augmentation of the air dedicated to the combustion process. An effort on the injection system design is required and large eddy simulation (LES) can be a useful tool in order to explore the design of novel concepts. At the state of the art, the validation of LES in high-pressure reactive conditions and in presence of the liquid phase is still limited. This shrinks the understanding and optimization of lean devices. The industrial project PERCEVAL, between Safran Tech and the CORIA laboratory, aims at extending the actual knowhow on lean combustion. Novel optical experimental techniques have been developed at CORIA to gain detailed information on industrial injection systems at high-pressure conditions. Within PERCEVAL, Safran Tech is in charge of the assessment of LES by using the experimental dataset collected at CORIA. In this framework, a novel automatic mesh convergence (AMC) procedure, based on adaptive mesh refinement, has been developed in the YALES2 platform to speed-up the calculation process. In the present paper, the AMC framework is described and then applied on the lean injection system designed at Safran Tech and tested during PERCEVAL. An analysis is carried out to evaluate the interest and gains offered by the AMC framework.

수학 예비교사가 국어, 과학, 윤리 예비교사와 함께 설계한 융복합 수업의 특징 탐색

This study was conducted with the purpose of analyzing the cases of convergence classes of pre-service teachers and providing information for conducting convergence classes in the secondary school. Mathematics pre-service teachers participated in a 4-week convergence class design and demonstration program with teachers of Korean language, Science, and Ethics to develop 51 convergence class cases, and I analyzed the characteristics of convergence classes in terms of class purpose, motivation context, convergence procedure, and student agency. The characteristics of each dimension were different depending on the subject integrated with mathematics. For example, convergence classes with the Korean language use a lot of statistics, and interdisciplinary procedures, and student-led classes are designed, and convergence classes with Science utilize a variety of mathematical knowledge, but multidisciplinary procedures are used and teacher-led classes are designed. Based on these results, the role of mathematics according to the purpose of the convergence class was presented, context, procedure, and student agency should be considered in designing convergence classes, considerations for convergence with Korean language, Science, and Ethics, and implications for convergence education and pre-service teacher education.

Convergent procedure for non-paroxysmal atrial fibrillation: a light in the darkness

Convergent procedure for non-paroxysmal atrial fibrillation: a light in the darkness

Abstract 14899: Ten Year Performance of Convergent Cryoballoon Hybrid Ablation With Left Atrial Appendage Exclusion in Persistent and Long Standing Persistent Atrial Fibrillation: A Trac-Af Registry Outcome Study

Introduction: Catheter ablation (CA) efficacy in persistent and long standing persistent atrial fibrillation (AF) remains poor. The Convergent procedure with endocardial cryoballoon and left atrial appendage exclusion (LAAE) addresses multiple epicardial/endocardial targets offering a comprehensive approach. We report clinical outcomes in a prospectively collected registry supplemented by continuous device monitoring in a diseased AF patient population. Methods: Single center patient data were retrospectively analyzed in the TRAC-AF registry (NCT05111015) between November 2011-November 2021. Epicardial ablations were performed by cardiothoracic surgeon and endocardial CA performed by electrophysiologist. Clinical follow up was performed at 3, 6, and 12 months and every 6 months thereafter. AF burden was determined from patients with ≥30 days of 24 hr continuous rhythm monitoring following a 90 day blanking period. Results: A total of 228 patients (69% male) received hybrid Convergent ablation. Mean age was 66 yrs, mean BMI was 30.2 ± 6.2, and in 70% of patients, CHA2DS2-VASc was ≥2. Baseline AF types were paroxysmal (7%), persistent (43%), and longstanding persistent (50%). Mean AF duration was 5.1 ± 6.2 yrs. Fifty-seven percent of patients had failed CA prior to hybrid ablation and 30.6% had LAAE with an epicardial clip. Of 228 patients, 114 (50%) had continuous rhythm monitoring. Mean residual AF burden was 5.2 ± 16.3% and of those, 77% had ≤1% mean residual AF burden, and 88% had ≤5% mean residual AF burden. A repeat CA after hybrid Convergent occurred in 23% (53/228) of patients at a mean 645.8 ± 511.4 days from the index procedure with 4.4% requiring &gt;1; 88.5% of all repeat ablations included a mitral annular line. Conclusions: The hybrid Convergent ablation with endocardial cryoballoon and LAAE provides long term sustainable low AF burden despite rigorous endpoint surveillance in a significantly diseased AF population which includes prior failed CA patients over a decade of follow up.