The Hybrid Ablation for Atrial Fibrillation Combines Surgery and Catheter Ablation — Video Interview with Dr. Andy Kiser
July 30, 2013
- Summary: Dr. Andy Kiser discusses the hybrid ablation (hybrid procedure) for atrial fibrillation, which combines a surgical procedure and catheter ablation
- Reading and watching time is approximately 5½ minutes
In this video interview, Dr. Andy Kiser discusses the hybrid ablation (also called the hybrid procedure) for atrial fibrillation. It combines a surgical procedure and catheter ablation in the same procedure in the same setting. It is done by a team that consists of both a surgeon and an electrophysiologist in what he considers to be a best of both worlds approach.
The hybrid procedure is done in a hybrid EP suite using both EP and surgical equipment, and incorporating electrophysiological testing to confirm that the erratic electrical signals have been blocked. Today it is done with a multipolar radiofrequency energy source that combines both unipolar and bipolar radiofrequency energy.
Those who have symptomatic atrial fibrillation and who have been in atrial fibrillation for a long period of time, or who have large left atriums or have failed multiple catheter ablations, are appropriate candidates for this procedure.
To learn more, view the video interview with Dr. Kiser (5 minutes)
About Andy Kiser, MD
Professor of Surgery
Chief, Division of Cardiothoracic Surgery
University of North Carolina
Chapel Hill, NC
For more information, see Dr. Kiser’s profile.
We have an important role as cardiac surgeons to work with our electrophysiologists to determine which patients are actually going to benefit from which procedure. There are a lot of different options for treating atrial fibrillation—medical, catheter ablation, surgical ablation—but I think that until we can tailor the treatment options for the specific patient, it’s hard to do the right thing, or know that we’re doing the right thing. So we always meet and talk about all our patients before we entertain any type of surgical or catheter ablation to make sure that that patient is getting the most tailored approach to their problem.
Patients who end up having surgical ablation, surgical treatments to their atrial fibrillation, at least at the University of North Carolina, have that in collaboration with electrophysiologists. What that means is that we take patients who have failed multiple catheter ablations, patients who have rather large left atriums, patients who have been in atrial fibrillation for a long period of time, all of them having symptomatic atrial fibrillation. But we look at them, not only what they were doing before, but we follow them after our procedures to make sure that the symptoms, those EKG changes, have resolved.
And in doing all this across the board, we’re able to better tailor the procedure to the patient that needs it. We may approach some population through the abdomen, through the diaphragm; we may approach another population through the chest in a mini thoracotomy. Others may get a full sternotomy and mitral valve repair with a cryoablation because they have more mitral valve regurgitation than we think, and they can handle, and will resolve their atrial fibrillation. So it’s a very tailored approach.
The transdiaphragmatic approach—we still use a monopolar [unipolar] energy source for that. And it’s more tailored for patients who are very, very sick, patients who have significant lung disease, patients who have a very significant compromise of their left ventricular function, or patients who have had previous cardiac surgery — previous bypass surgery, previous valve surgery.
Most of the time, we approach patients from a concomitant standpoint now, with electrophysiologists, through the chest—either with port access or with a mini thoracotomy. The [Estech] Fusion device that is now on the market combines bipolar and unipolar energy. By doing the procedure in concert with the electrophysiologist, we can not only do good ablations and verify them at the time of the procedure, but we can now incorporate the electrophysiology tools into the surgical approach. So when I’m doing an afib ablation, I’m also monitoring the electrical activity of their heart and I’m mapping their epicardium with an electrode; it just gets us a much better overall procedure.
Are you working with the EPs in the EP lab or operating room?
It’s actually in the hybrid EP suite. So it’s a hybrid room with X-ray machines, but also the highly-technical arrhythmia-monitoring devices that the EPs use. So we use CARTO imaging, we use high-density electrograms, we use high-frequency electrogram mapping with multipolar electrodes. All these things we use instead of just during the EP portion, but also during the surgery portion, which helps us, I think, give a better surgical ablation.
What have you learned from doing the hybrid approach?
The first thing I learned was that I was not an electrophysiologist, I was an anatomist. Dr. Cox first described the afib procedure, with his cut-and-sew maze, as an anatomical approach to atrial fibrillation. It wasn’t an electrical mapping of the heart; Dr. Cox just made scars on the heart with an incision, and it blocked all the re-entry circuits.
Some of the very recent data of mapping the left atrium during atrial fibrillation has allowed us to identify potentially the very source of the afib. Some of the work in California now shows electrophysiologists going in and ablating a single focus of atrial fibrillation that’s mapped by a cycle that converts patients from atrial fibrillation to sinus rhythm.
If I didn’t know a lot about that, then imagine what the electrophysiologists didn’t know about the surgical part of it. By working together with electrophysiologists, it’s the best of both worlds, it really is, because I’m learning more and more about what they think is success, and they learn what I think is success. And together, it’s successful.
But it’s not just the procedure, it’s what happens before the procedure—it’s the monitoring, it’s the medications post-operatively, managing the antiarrhythmics. It’s much more of a team approach to the treatment of atrial fibrillation.
I do think the opportunities for atrial fibrillation treatment are that we’re just scratching the surface. Some of the newer things that are coming along, with MRI mapping, and this rotor mapping, the newer devices coming along for surgery, are exciting. And it’s a wonderful time to be helping patients with atrial fibrillation.