Page 26 - ADD-ON ABLATION SURGERY IN PATIENTS WITH ATRIAL FIBRILLATION

Chapter 1
However, all these percentages were not the result of a meta-analysis of quantitative studies. Furthermore, the small number of patients undergoing minimally invasive surgery without a concomitant LAA procedure does not allow us to draw any conclusions. Finally, it still remains unclear whether it is better to retain the LAA, which largely contributes to left atrial booster function146.
The hybrid approach
The concept of the ‘hybrid’ procedure was first published by Pak et al.147 who combined percutaneous epicardial catheter ablation (PECA) and endocardial ablation in difficult cases of AF.
More recently, Krul et al.148 presented their experience with thoracoscopic PV isolation and ganglionated plexus (GP) ablation guided by peri-procedural electrophysiological testing resulting in a single-procedure success rate of 86%. Mahapatra et al.149 have recently published their initial experience with surgical epicardial-catheter and endocardial ablation for persistent and long-standing persistent AF carried out in two sequential steps. After a mean follow-up of 20.7 ± 4.5 months, 86.7% patients were free of any atrial arrhythmia and off of antiarrhythmic drugs (AADs).This percentage was 53.3% in patients undergoing a catheter-alone procedure (p= 0.04). Our group had previously published experience with the hybrid procedure performed in two steps: 17 patients first had endocardial catheter isolation of PVs and due to recurrence of persistent AF were selected for the epicardial approach (29% in SR at 25.7 ± 12-month follow-up) whereas 20 patients first underwent an epicardial procedure with a subsequent completion of PV isolation (55% in SR at 33.4 ± 12-month follow- up) 150. More recently, we have introduced in our practice a sequential ‘one-step’ approach including an epicardial procedure followed by endocardial catheter radiofrequency. One-year off-AAD success rate free of AF/atrial flutter/atrial tachycardia was 93% for patients with paroxysmal AF and 90% for patients with persistent AF151.
The hybrid approach presents some potential advantages:
1. There is no risk of tamponade during the trans-septal puncture since the
pericardium is open.
2. Since the surgical ablation device is located on the antrum of the left
atrium and left as a radiopaque marker, it is almost impossible to create stenosis of the PVs.
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