Initial experience of sequential surgical epicardial-catheter endocardial ablation for persistent and long-standing persistent atrial fibrillation with long-term follow-up

Abstract

Background: Patients with long-standing persistent (LSP) atrial fibrillation (AF) who have previously undergone catheter ablation represent a challenging patient population. Repeat catheter ablation in these patients is arduous and associated with a high failure rate, whereas surgical ablation can be complicated by multiple flutters. We sought to determine if minimally-invasive surgical ablation, followed by catheter ablation of all inducible flutters, would improve success rates over repeat catheter ablation alone.

Methods: Fifteen patients (Sequential) with persistent or LSP AF who failed at least one catheter ablation and one anti-arrhythmic drug (AAD) underwent surgical ablation, followed by planned endocardial evaluation and catheter mapping with ablation during the same hospitalization. Sequential patients were matched to 30 patients who had previously failed at least one catheter ablation and underwent a repeat catheter ablation (catheter-alone). The primary end point was event-free survival of any documented AF recurrence or AAD use.

Results: All patients underwent uncomplicated surgical ablation and electrophysiology procedure. Five Sequential patients had seven inducible flutters that were mapped and ablated. After a mean follow-up of 20.7±4.5 months, 13/15 (86.7%) Sequential patients, but only 16/30 (53.3%) catheter-alone patients, were free of any atrial arrhythmia and off of AAD (p=0.04). On AAD, 14/15 (93.3%) Sequential patients were free of any atrial arrhythmia recurrence, compared to 17/30 (56.7%) catheter-alone patients (p=0.01).

Conclusions: For patients with atrial fibrillation who have failed catheter ablation, Sequential minimally invasive epicardial surgical ablation, followed by endocardial catheter-based ablation, has a higher early success rate than repeat catheter ablation alone.

Fig 1

Schematic representation of epicardial (bold) and endocardial (dashed) ablation lines for Sequential procedure.

Fig 2

Electrophysiology procedure flow chart. (AF = atrial fibrillation; CFAE = complex fractionated atrial electrogram; CS = coronary sinus; CV = cardioversion; LI-MI Line = from left inferior pulmonary vein to mitral valve; PVs = pulmonary veins; SVC = superior vena cava.)

Fig 3

Results of Sequential electrophysiology study. Atrial fibrillation (AF)-alone was induced in 2, and 7 atrial flutters were induced in 5. (CFAE = complex fractionated atrial electrogram; CTI = cavotricuspid isthmus; CV = cardioversion; LAA = left atrial appendage; LSPV = left superior pulmonary vein; PV = pulmonary vein; SR = sinus rhythm; SVC = superior vena cava.)

Fig 4

Location of gaps found at electrophysiology study: 4/15 gaps on roof line, and 4/15 had a presumed gap in line to mitral valve.

Fig 5

Overall freedom from recurrence of atrial arrhythmia or anti-arrhythmic drug (AAD) use for all patients undergoing Sequential versus catheter-alone ablation.

Fig 6

Overall freedom from recurrence of atrial fibrillation for all patients undergoing Sequential versus catheter-alone ablation, while on anti-arrhythmic drug (AAD) therapy.