Transvenous Before Surgical Hybrid Procedure

Joseph J. Tiano, MD; Robert Drennan, MD; John Novella, MD; Rafael Squiteri, MD; Malcolm Robinson, MD; Albert DiMeo, MD; Lindsey Scierka, MPH; Paul LeLorier, MD


Background: Historically, persistent atrial fibrillation (PeAF) and long standing persistent atrial fibrillation (LSPeAF) have demonstrated limited clinical success despite hybrid approaches.  

Objective:  We describe our experience with the endocardial-before-epicardial approach defined by a comprehensive endovascular approach preceding and guiding the epicardial approach which includes an extensive posterior wall ablation.  

Methods: 40 patients were followed over a 12 month period.  The procedure was performed in a single center.  Patients had a mean duration of atrial fibrillation of 6.0 ± 4.5 years with 22.5% having undergone prior ablations.  Mean age was 61.7 ± 7.9 years with a mean left atrial volume of 131.5 ± 46.9 mL.  The endovascular procedure remained uniform with antral pulmonary vein isolation, posterior left atrial roof and right atrial cavo-tricuspid isthmus (CTI) linear lesions with mapping and ablation of left atrial complex electrograms (CFAEs) and prior existing atrial arrhythmias.  The epicardial procedure included a thorascopic approach with ganglionated plexus (GP) mapping and ablation, left atrial posterior wall ablation, directed CFAE ablation and left atrial appendage ligation.  All patients received implantable cardiac monitoring.

Results: All 40 patients remained in sinus rhythm at their 12 month follow-up.  During the monitoring period, episodes of paroxysmal atrial arrhythmias including fibrillation were documented, without persistence, after discontinuation of oral antiarrhythmic medications.  

Conclusion: The endo-before-epi approach resulted in improved management of persistent and long standing persistent atrial fibrillation over reported results for conventional approaches with no procedural complications, making this a promising option for the management of these arrhythmias. 


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