Simultaneous Hybrid Ablation Of Long-standing Persistent Atrial Fibrillation: Advanced Mapping Technologies To Guide Surgical Ablation
Gianluigi Bisleri1, Malak Elbatarny1, Sanoj Chacko1, Adrian Baranchuk1, Kathryn Hong1, Michael Kahn1, Gary Tse2, Benedict Glover1.
1Queen's University, Kingston, ON, Canada, 2Chinese University of Hong Kong, Hong Kong, Hong Kong.
BACKGROUND: Hybrid surgical and transcatheter ablation has recently emerged as an attractive strategy to address long-standing persistent atrial fibrillation (LsP-AF). In particular, the availability of advanced endocardial mapping technologies can provide further guidance to improve the effectiveness of epicardial surgical ablation, in particular when a linear ablation device is utilized. METHODS: Eight patients (mean age: 65.7±8.6 yrs) with LsP-AF were enrolled and underwent a simultaneous hybrid ablation procedure: mean AF duration was 94 months (range: 12-368) and LA volume index was 38.5±10.5 mL. Two patients (25%) were female, as well as 25% of the study population had a history of stroke and prior transcatheter ablations. Mean LVEF was 61.2±6.6%. Three validation techniques were used intraoperatively: continuous pulmonary veins (PVs) potentials monitoring; baseline and post-procedural 3D high-density automated LA voltage mapping (Figure 1); and entrance/exit block testing. LA voltage mapping combined impedance and magnetic field technology. Thoracoscopic epicardial en-bloc PVs isolation was performed using a linear radiofrequency ablation device combining uni and bipolar radiofrequency energy. RESULTS: Procedural success was achieved in all cases; 7/8 underwent additional thoracoscopic LAA exclusion with an epicardial clip. Duration of epicardial ablation averaged 22.5±3.3 mins, including targeted applications guided by PVs potential changes. Gaps noted on the final voltage maps were addressed with additional ablations, either epicardially (2 pts) or endocardially (3 pts); furthermore, a mitral isthmus line and a cavo-tricuspid lesion were performed in 1 pt respectively. All patients converted intra-operatively to sinus rhythm, which is maintained at a mean follow-up of 76 days (range: 2-161); anti-arrhythmic medications have been discontinued in all patients beyond the 3 months blanking period (4/8 pts). No stroke or major procedure-related morbidity occurred post-operatively. CONCLUSIONS: Advanced electrophysiological mapping during simultaneous hybrid ablation of LsP-AF can be useful to improve the effectiveness of epicardial surgical ablation with a linear device. Further investigation on a larger series of patients and with a longer follow-up is warranted to confirm these preliminary findings. LEGEND: Figure 1. Baseline and post procedure 3D high density voltage mapping of the LA. Complete isolation of the posterior wall is confirmed (red areas)
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