Efficacy and Safety of Hybrid Ablations for Atrial Fibrillation

Quick Takes

  • Sixty percent of patients had evidence of chronic cerebral ischemic lesions before thoracoscopic ablation, and 44% of patients had new ischemic lesions post-procedure.
  • Major postoperative cognitive dysfunction was present in 27% of patients at 1 month and 18% at 9 months postoperatively.
  • The probability of arrhythmia-free survival was 54% at 1 year and 44% at 2 years.

Study Questions:

What is the procedural safety and midterm efficacy of hybrid ablations in nonparoxysmal atrial fibrillation (AF)?

Methods:

Patients underwent thoracoscopic ablation followed by catheter ablation 3 months afterward. The safety of the procedure was assessed using sequential brain magnetic resonance and neuropsychological examinations at baseline, postoperatively, and at 9 months after the surgical procedure. Implantable loop recorders were used to detect arrhythmia recurrence. Arrhythmia-free survival was the primary efficacy endpoint.

Results:

A total of 59 patients (mean age 63 years) were enrolled; mean follow-up was 30 months. Thoracoscopic ablation was successfully performed in 55 (93.2%) patients. On baseline magnetic resonance imaging, chronic ischemic brain lesions were present in 60% of patients. New ischemic lesions on postoperative magnetic resonance imaging were present in 44%. Major postoperative cognitive dysfunction was present in 27% of patients at 1 months and 18% at 9 months postoperatively. The probability of arrhythmia-free survival was 54% at 1 year and 44% at 2 years.

Conclusions:

The authors concluded that thoracoscopic ablation is associated with a high risk of silent cerebral ischemia, and that the midterm efficacy of hybrid ablations is moderate.

Perspective:

Hybrid ablation has been developed to address the complex arrhythmogenic substrate often found in patients with nonparoxysmal atrial fibrillation. The procedure entails thoracoscopic ablation followed by catheter ablation. In this study, surgical ablations were performed using a thoracoscopic, off-pump, epicardial approach with the goal to create a circumferential lesion anterior to the pulmonary veins to isolate all the pulmonary veins together with the posterior aspect of the left atrium (i.e., a box lesion set) in one fell swoop. The electrophysiology (EP) study and catheter ablation were performed approximately 2-3 months after the surgical ablation. The EP study was used to confirm the isolation of the box lesion, create a mitral isthmus line, and ablate the cavotricuspid isthmus. This study did not have a control arm, and a direct comparison with catheter-only procedure is not possible. However, this manuscript demonstrates that this resource-intensive two-step procedure was associated with relatively poor efficacy, a high risk of silent cerebral ischemia, and postoperative cognitive decline, raising the question of the procedure’s place in the rhythm control armamentarium.

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Brain Ischemia, Catheter Ablation, Electrophysiology, Heart Atria, Magnetic Resonance Imaging, Magnetic Resonance Spectroscopy, Myocardial Ischemia, Postoperative Cognitive Complications, Pulmonary Veins, Thoracoscopy


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