Editor's Note: This Article of the Month is based on Pison L, Meir ML, Opstal J, Blaauw Y, Maessen J, Crijns HJ. Hybrid thorascopic surgical and transvenous catheter ablation of atrial fibrillation. J Am Coll Cardiol 2012;60:54-61.

Introduction

Atrial fibrillation (AF) is a challenging disease to treat in symptomatic patients. Anti-arrhythmic drugs have limited long term efficacy. For many of these patients, non- pharmacologic therapy is often the only option for controlling symptoms. Non-pharmacologic therapy for atrial fibrillation consists of either catheter or surgical ablation of  the left atrium. Surgical ablation has evolved from the extensive bi-atrial lesion set developed for the Cox maze procedure to a series of bipolar radiofrequency ablation lesions delivered via a thorascopic approach localized to the pulmonary veins. Catheter based radiofrequency ablation has also evolved tremendously over the last 15 years, but is now focused on ablation around the pulmonary vein antrum. Additional lesions are often applied in patients with persistent AF. Despite the existence of both of these invasive ablation approaches for many years, there are few clinical trials comparing the two different approaches.⁽¹⁾ Both of these procedures have lower than ideal success rates, primarily attributed to our inability to make long lasting ablative lesions in the left atrium. However, more recently the novel idea of combining a catheter based and surgical approach has been developed with the hypothesis that one is more likely to make durable and continuous lesions using a combination of energy delivery from the endocardium and the epicardium. The purpose of the present study is to evaluate the efficacy and safety of this new approach.

Methods

The hybrid procedure was tested in 26 patients, of whom 11 (42%) had prior catheter ablation for either atrial fibrillation or atrial flutter and 11 (42%) had persistent atrial fibrillation. The specific hybrid procedure that was tested consisted of bipolar epicardial radiofrequency ablation of the pulmonary veins, creation of a roof  line, an inferior left atrial line, a mitral isthmus line, encircling superior caval vein, and connecting it to the inferior cava and catheter based measurement of entrance and exit block from circular catheters placed inside the pulmonary vein antrum, cryoballoon ablation of the left pulmonary veins in patients with severe chronic obstructive pulmonary disease, cavo-tricuspid isthmus ablation if a prior history of atrial flutter was present, ablation of gaps in the roof and inferior left atrial line, and ablation inside the coronary sinus or near the mitral annulus for a left atrial isthmus line. Only three patients had a mitral isthmus line, only patients with a dilated right atrium had right atrial lesions, and not all patients had a left atrial box lesion set. Follow up consisted of 7-day continuous Holter monitors at 3, 6, 9, and 12 months. Failure was defined as 30 seconds or more of any atrial arrhythmia.

Results

There were no complications identified, however one patient was hospitalized for 13 days due to severe chest pain and one patient had a pleural effusion drained at 3 weeks. The mean follow up was 470 days. In 23% of patients, endocardial ablation was performed during the hybrid procedure. One-year success was 93% for patients with paroxysmal AF and 90% for patients with persistent AF. Two patients underwent repeat catheter ablation for recurrent atrial arrhythmias, and two patients were treated with anti-arrhythmic drugs for recurrent AF.

Conclusion

A combined hybrid procedure may be particularly useful for patients with persistent AF with a very high single procedure success rate at one year.

Editorial Perspective

The authors are to be commended for trying this approach and specifically for performing such extensive catheter and surgical ablation with exemplary results and avoiding cardiac bypass. They have performed extensive surgical ablation in a particularly challenging group of patients with results that are significantly better than what others have reported in the literature due to very extensive bi-atrial ablation. In other words, reading between the lines, the more extensive the disease structurally and electrically, the more extensive the ablation. Their short-term results are excellent, but as we have seen in this disease with both surgical and catheter ablation, recurrences continue over time. I think this approach needs further investigation, and must be compared to approaches where catheter ablation is performed later, in patients with recurrences only. The advantages of staging catheter ablation as a second procedure vs. simultaneous with the surgical ablation will require further careful study.

References

1. Boersma LVA, Castella M, Boven WV, Berruezo A, Yilmaz A, Nadal M, Sandoval E, Calvo N, Brugada J, Kelder J, Wijffels M, Mont L. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST). A 2 center randomized trial. Circulation 2012;215:23-30.
2. Pison L, Meir ML, Opstal J, Blaauw Y, Maessen J, Crijns HJ.  Hybrid thorascopic surgical and transvenous catheter ablation of atrial fibrillation.
   J Am Coll Cardiol 2012;60:54-61.

Keywords: Atrial Fibrillation, Atrial Flutter, Catheter Ablation, Chest Pain, Coronary Sinus, Endocardium, Pleural Effusion

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