Hybrid atrial fibrillation ablation

Abstract

In this state-of-the art review on hybrid atrial fibrillation (AF) ablation, we briefly focus on the pathophysiology of AF, the rationale for the hybrid approach, its technical aspects and the efficacy and safety outcomes after hybrid AF ablation, both from meta-analyses and randomized control trial data. Also, we performed a systematic search to provide a provisional overview of real-world hybrid AF ablation efficacy and safety outcomes. Furthermore, we give an insight into the 'Maastricht approach', an approach that allows us to tailor the ablation procedure to the individual patient. Finally, we reflect on future perspectives with the objective to continue improving our thoracoscopic hybrid AF ablation approach. Based on the review of the available literature, we believe it is fair to state that thoracoscopic hybrid AF ablation is a valid alternative to catheter ablation for the treatment of patients with more persistent forms of AF.

Keywords: Hybrid ablation; atrial fibrillation (AF); expert review; keynote lecture.

Figure 1

Schematic overview of the relationship between risk factors, pathogenic factors and different types of remodeling in AF patients. See text for explanation. AF, atrial fibrillation.

Figure 2

Schematic overview of the theoretic role of triggers and substrate within the progression from paroxysmal AF to persistent AF. See text for explanation. AF, atrial fibrillation.

Figure 3

Advantages of the epicardial and endocardial approach within the hybrid procedure and comparison of the advantages of a single-staged with a two-staged hybrid AF ablation. LAA, left atrial appendage; RF, radiofrequency; OR, operating room; EP, electrophysiology; AT, atrial tachycardia; ATA, atrial tachyarrhythmias.

Figure 4

Advantages of the close cooperation between the surgeon and the electrophysiologist within the hybrid approach. (A) Epicardial isolation of the SCV using an irrigated bipolar biparietal RF clamp. Clamp is in open position. (B) Same as (A), but with the clamp in closed position. (C) Transvenous endocardial validation of the SCV lesion. (D) Resulting voltage map showing an isolated SCV, PVI and box lesion. (E) Electrograms during endocardial validation showing dissociated activity in the SCV. Upper tracings [3] show the surface ECG (white). Light blue tracings show the signals of the Pentaray catheter (Biosense Webster, CA, USA) in the SCV. The local ectopic signals are not in relation with the surface ECG, demonstrating entrance block over the SCV line. SCV, superior caval vein; RA, right atrium; PV, pulmonary vein; LA, left atrium; ECG, electrocardiogram; SR, sinus rhythm; CS, coronary sinus; RF, radiofrequency; PVI, pulmonary vein isolation.

Figure 5

Different epicardial ablation approaches during a hybrid AF procedure in Maastricht. The upper figures (green background) show port positions and epicardial (yellow) and endocardial (green, only in C) ablation lesions on the dorsal part of the heart. Lower figures (salmon-pink background) show the different devices and their position during ablation on the dorsal part of the heart. Of note, the left atrial appendage exclusion is not shown. (A) Bilateral thoracoscopic access using a bipolar biparietal irrigated RF clamp. The lesions from the right and the left side overlap in the middle, thereby isolating the pulmonary veins, the posterior wall and the ligament of Marshall in one continuous lesion. The superior caval vein can be isolated as well. (B) Unilateral left sided thoracoscopic access using a bipolar biparietal dry RF clamp and bipolar uniparietal dry RF linear device. Right and left antral pulmonary vein isolation is performed with the RF clamp, both from the left side. Roof and floor lines are created with the linear RF device. (C) The convergent procedure: subxiphoid posterior wall isolation using a unipolar uniparietal dry RF catheter. Endocardial completion of right and left pulmonary veins and often also of the box lesion is mandatory. In Maastricht, this procedure is reserved for patients unfit to undergo thoracoscopic hybrid AF ablation. AF, atrial fibrillation; RF, radiofrequency.

Figure 6

Pooled Kaplan-Meier curve showing freedom of ATA recurrence until 36 months after hybrid AF ablation in consecutive patients. Kaplan-Meier curves were extracted from the original papers reporting on consecutive patients undergoing hybrid AF ablation, together with the numbers at risk. The reconstructed time-to-event data were presented in a new pooled Kaplan-Meier curve, with a stratification for freedom from ATA recurrence allowing AADs (blue line) and off AADs (red line). ATA, atrial tachyarrhythmia; AF, atrial fibrillation; AAD, antiarrhythmic drugs.

Figure 7

Stepwise overview of a patient individualized hybrid AF treatment approach in the MUMC+. See text for explanation. AF, atrial fibrillation; pAF, paroxysmal AF; persAF, persistent AF; LAD, left anterior descending artery; MIDCAB, minimally invasive direct coronary artery bypass; LAVI, left atrial volume index; LCEF, left ventricular ejection fraction; PVI, pulmonary vein isolation; SCV, superior caval vein; LAA, left atrial appendage; MI, mitral isthmus; ATA, atrial tachyarrhythmia; AFL, atrial flutter; CTI, cavo-tricuspid isthmus; ECV, electrical cardioversion; SR, sinus rhythm; EP, electrophysiological.

Video

Hybrid atrial fibrillation ablation.