Hybrid Ablation Procedures for Atrial Fibrillation
Hybrid ablation is a minimally invasive (not open-heart) dual approach. First, a cardiac (cardiothoracic) surgeon performs a mini maze surgical ablation procedure on the outside of the heart. Then, an electrophysiologist does a catheter ablation on the inside of the heart. Hybrid techniques may improve success and minimize risks as they combine the strengths of catheter ablation and a mini maze procedure and minimize any limitations of either alone.
A hybrid ablation is an emerging treatment for patients with more severe atrial fibrillation. This combined approach is investigational, with clinical trials being conducted to determine the safety and effectiveness for persistent and longstanding persistent afib. Combining both procedures may enhance the prospects that ablation lines fully penetrate all layers of the cardiac tissue, which is crucial to stopping afib. In addition, higher success rates and fewer complications may be possible as each specialist (electrophysiologist and surgeon) treats areas of the heart best suited to each of their approaches. This could improve success for those with persistent or longstanding persistent afib who want a minimally invasive (closed chest) approach.
As described below, the hybrid procedure and the convergent procedure are similar as they both combine surgery and catheter ablation. However, each uses a different entry point into the body and a different type of radiofrequency device.
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The hybrid procedure involves two procedures, surgery and catheter ablation.
The surgical part of the procedure is minimally invasive surgery. It requires a thoracoscopy (camera) to gain access to the heart. Three small incisions are made in the patient’s chest between the ribs (typically on both sides) to insert the scope and surgical instrument to access the heart. Under general anesthesia, the surgeon uses the bipolar radiofrequency clamp to ablate on one side of the heart. The surgeon then moves to the other side of the body to access the pulmonary veins on the other side of the left atrium and finishes the ablation using the same lesions as the maze surgery. Moving from one side to the other requires deflating the lungs (one side at a time). The procedure is finished by closing off the left atrial appendage.
Then, either on the same day or within a few days to months, the catheter ablation portion of the procedure is performed. The electrophysiologist uses a catheter (inserted through a blood vessel in the patient’s groin, arm, or neck) to reach the heart’s left atrium. Radiofrequency or cryoballoon energy is used to touch up or fill in any gaps in the scar tissue.
There are thought to be advantages and disadvantages to simultaneous and staged approaches. For example, the staged approach increases the likelihood of discovering incomplete lesions. In contrast, the simultaneous approach is more convenient for the patient. It does not require two separate hospital stays and anesthesia. Both approaches are currently under investigation.
Currently, the Staged DEEP trial, a feasibility study, is being conducted among those with persistent or longstanding persistent afib. It compares a minimally invasive surgical ablation with the bipolar radiofrequency clamp done in conjunction with a catheter ablation (1–10 days later) to catheter ablation alone.
The convergent procedure is different from the hybrid procedure. It uses a single-entry point with a scope inserted through a small incision. This subxiphoid incision is made just below the lower end of the sternum and into the sac that surrounds the heart, called the pericardial space. Then, the surgeon creates a series of linear lesions on the surface of the heart using a radiofrequency device.
The catheter ablation portion of the procedure is done on the same day, immediately following surgery. First, the electrophysiologist inserts the catheter using conventional methods (via the groin, arm, or neck) to access the heart’s left atrium. Then, the electrophysiologist fills in any gaps in the ablation using radiofrequency energy (unipolar or bipolar catheter) or cryo energy (cryoballoon catheter).
The convergent procedure takes approximately 4–5 hours. Advantages include that the procedure is done with a single incision rather than ports and without deflating the lungs. Limitations include a less robust overall lesion set, more reliance on catheters, limited access to the left atrial appendage and a requirement for other devices to manage it, and the entire procedure must be completed the same day.
The CONVERGE clinical study in the US and the UK evaluated the safety and effectiveness of the convergent procedure compared to traditional radiofrequency catheter ablation in patients with persistent (88 patients, 58%) and longstanding persistent afib (65 patients, 42%). In addition, patients were allowed to have a larger left atrium.
The convergent procedure had superior effectiveness compared to catheter ablation alone in treating persistent and longstanding persistent afib. The study results showed that at 12 months, 67.7% (67/99) of patients with a convergent procedure were free from afib, atrial flutter, and atrial tachycardia and either on or off previously failed antiarrhythmic drugs. That compared to 50.0% (25/50) for those who had catheter ablation alone.
In addition, for those off of antiarrhythmic drugs, 53.5% (53/99) of those who had a convergent procedure were free from afib, atrial flutter, and atrial tachycardia compared to 32.0% (16/50) who had catheter ablation alone.
At 18 months using a 7-day Holter monitor, 74.0% (53/72) of those who had the convergent procedure had more than a 90% reduction in afib burden compared to only 55% (23/42) of catheter ablation patients.
To learn more about the procedures that make up the hybrid ablation procedure, see catheter ablation and mini maze procedure. To learn more about stroke prevention devices that can be implanted in conjunction with catheter ablation or surgery, see Left Atrial Appendage Occlusion Devices.
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