Introduction: Atrial fibrillation (AF) affects over 50 million people worldwide. Although ablation therapy has evolved, the success rates for persistent AF remain suboptimal. The minimally invasive hybrid approach for ablation is an emerging form of therapy to successfully restore sinus rhythm (SR) in patients with longstanding persistent AF.
Methods: We conducted a prospective, single-centre UK study over a 3.5-year period to assess the efficacy and outcomes using the hybrid technique in patients with longstanding (>1 year) persistent AF. The hybrid ablation procedure was undertaken in two stages. The first stage (stage one) was a minimally invasive thoracoscopic epicardial ablation via three small ports to access the pericardial space for epicardial ablation of the posterior left atrium (LA) and pulmonary veins (PVs) using the AtriCure radiofrequency system. This was followed by transvenous endocardial approach (stage two) via the femoral veins to endocardially isolate the PVs ± posterior LA wall, with the use of either cryo-balloon (for PV isolation only) or radiofrequency ablation.
Results: Sixty-three patients with persistent AF were enrolled for hybrid ablation. Two patients were excluded for reasons of anatomical restrictions to epicardial access. Mean age of the patients was 65 years and the mean BMI was 31. Males constituted 75% of the study cohort. Mean LA size was 45 mm and mean left ventricular ejection fraction (LVEF) was 56.5%, although 30% of patients had LVEF below 50%. Thirty-five patients had more than 3 months follow-up data following stage two ablation, with mean follow-up of 16 months. Thirty-one (88.6% [CI 0.7–0.9]) of the patients remained in SR at last follow-up, whereas four (11.4% [CI 0.04–0.2] patients had redeveloped persistent AF. The incidence of major complications in all 61 patients during stage one ablation was low, with IVC rupture in one patient. A mild stroke occurred in one patient, port-site infection in one patient, and port-site seepage of blood in one patient. Median LOS was 1 day (1–4 days) and there was no patient mortality.
Conclusions: The initial results are promising, with a conversion rate of 88.6% at 16 months and predominantly 1-day LOS for stage one ablation. There are minimal major complications, with no mortality.