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Trans Xyphoid Hybrid Catheter and Surgical Ablation with Left Atrial Appendage Occlusion
Andy C. Kiser, Paul Mounsey, Sruthi Cherkur, Kelly Garner, Anil Gehi.
University of North Carolina, Chapel Hill, NC, USA.

OBJECTIVE: Trans Xyphoid Surgery (TraXS) for hybrid catheter and surgical ablation (HyCASA) with left atrial appendage (LAA) occlusion to treat atrial fibrillation (AF) may be more effective than independently performed endocardial or epicardial ablation. We compare TraXS-HyCASA with LAA occlusion to trans-diaphragmatic unipolar and trans-thoracic integrated bipolar/unipolar techniques.
METHODS: Fourteen patients with long-standing persistent (1) or persistent (13) AF underwent totally trans-xyphoid extra-peritoneal HyCASA using integrated bipolar/unipolar radiofrequency (RF) and irrigated catheter RF energy. Epicardial ablation targeted isolation of the pulmonary veins, the posterior LA, and the lateral RA and was immediately followed by endocardial ablation to complete, where necessary, the epicardial lesion set and to ablate complex fractionated electrograms and any residual atrial flutter. Continuous monitoring using an implantable device after a 3-month blanking period was used for follow-up in all patients. These were compared to a trans-diaphragmatic unipolar group (n=38) and a right mini-thoracotomy trans-thoracic integrated bipolar/unipolar RF group (n=29).
RESULTS: All patients underwent successful TraXS-HyCASA with no peri-procedural mortality or stroke. All had failed antiarrhythmic drug therapy and 71% had failed prior endocardial ablation (mean 1.6 ablations). Age was 61 yrs (+9.1) and 72% were male. Left atrial size was 4.9 (+0.8) (range: 3.4-6.1) cm; ejection fraction was 55 (+8.7) (range 35-65) %. AF Duration was 10.1 (range:0.5-27) yrs. Patients undergoing TraXS-HyCASA were more likely to be persistent, had no increased post-procedure length of stay, and had no bleeding complications (Table 1). The average procedure time was similar for the TrACS patients yet they required significantly fewer endocardial lesions and fluoroscopy time. All but 2 TraXS-HyCASA patients had successful LAA occlusion confirmed by intraoperative transesophageal echocardiogram whereas LAA occlusion could not be performed during the procedure in the other groups.
CONCLUSIONS: TraXS-HyCASA AF ablation using integrated bipolar/unipolar RF has favorable procedural outcomes, enables creation of a comprehensive ablation pattern, and enables successful closure of the LAA. Success at maintaining sinus rhythm in follow-up is currently being evaluated.

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