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OBJECTIVE: Aim of this study is to evaluate feasibility, safety and mid-term efficacy of a hybrid sequential approach to persistent ad long-standing persistent AF consisting in a combination of thoracoscopic surgical ablation plus left appendage exclusion and a subsequent trans-catheter EP ablation.
METHODS: Between April 2010 and June 2013, 24 patients (60,3±7,6 y.o.) with persistent or long-standing persistent AF (60,3±7,6 mo.), mean left atrial diameter 46,4±5,5 mm and mean LVEF 53,2±11,1% underwent to closed-chest, video-assisted thoracoscopic epicardial anatomical pulmonary veins isolation or box lesion performance with bipolar or unipolar radiofrequency and left appendage closure with external clip. No block was tested across the lines during surgical procedure. Subsequently, after a mean period of 2 months, we proceeded to trans-catheter EP evaluation for electro-anatomical mapping, gaps touch-up, adjunctive substrate reduction and possible right side cavo-tricuspid isthmus line. Follow-up was prospectively conducted with clinical evaluation and 24 hours Holter ECG at 3-6, 9, 12, 18 and 24 months.
RESULTS: There were no major complications, nor deaths. After a mean period of 15,4±8 mo. 18 (75%) patients were in stable SR and 13 (54.2%) were free from oral anti-coagulants drugs. Trans-catheter gaps touch-up of surgical lines was required in 8 (33,3%) patients. In 18 (75%) patients left appendage was successfully excluded. No stroke, nor TIA happened during follow-up period. At the end of follow-up period significant improvement in LVEF was noticed (53,2±11,1 vs. 61,9±9,2 p 0,001).
CONCLUSIONS: Hybrid sequential ablation for persistent and LS persistent AF can be safely performed with satisfying success-rate at mid-term follow-up.
Improvement in cardiac performance seems to characterize the clinical result. Adding an entrance/exit block test during surgery may help in improving thoracoscopic procedure success-rate. Left appendage exclusion can be safely performed in the setting of minimally invasive lone atrial fibrillation surgical ablation. In this context, adding such a procedure may help in maximizing immediate clinical result and improving long-term outcome.